topic tracheobronchial tree upper airway.pptx

topic tracheobronchial tree upper airway topic tracheobronchial tree upper airwaytopic tracheobronchial tree upper airwaytopic topic tracheobronchial tree upper airway tree upper airwaytopic tracheobronchial tree upper airway topic tracheobronchial tree upper airwaytopic tracheobronchial tree upper airwaytopic topic tracheobronchial tree upper airway tree upper airway

1. ANATOMY OF TRACHEO BRONCHIAL TREE, UPPER AIRWAY, CLINICAL APPLICATION, TRACHEOBRONCHIAL TREE IN NEWBORN DR ANANTHAKRISHNAN

2. Upper airway Nasal cavity Oral cavity Pharynx Larynx to lower border of cricoid cartilage

3. Nose External nose & nasal cavity

4. External nose Upper framework of bone- nasal bone nasal part of frontal frontal process of maxilla Series of cartilages in lower part Fibrofatty tissue-forms lateral margin of the nostril Cartilage of the nasal septum provides central support

5. Nasal cavity Divided by nasal septum Opens to exterior by nares , Opens into nasopharynx by choanae vestibule

6. BOUNDARIES Roof - Nasal and frontal bones Cribriform plate of ethmoid Body of sphenoid Floor – Concave from side to side and slightly so from before backwards Palatine process of maxilla and Horizontal plate of palatine Medial wall- septum Lateral wall

7. MEDIAL WALL-SEPTUM

8. LATERAL WALL

9. BLOOD SUPPLY OF NASAL SEPTUM

10. Nerve supply

11. FUNCTIONS OF NOSE Respiratory pathway Olfaction Resonator in speech Defense against microorganisms Strong inborn reflex to breathe through nose- natural for babies during suckling Packing the nose after surgery may cause restlessness upon emergence from an anesthetic

12. KRATSCHMER REFLEX stimulation of anterior part of nasal septum leads to constriction of bronchioles

13. CLINICAL-NASAL INTUBATION Major nasal air passage- lies beneath inferior concha Nasogastric tube should be encouraged to use this passage Force must never be used

14. MOUTH- ORAL CAVITY

15. PHARYNX NASOPHARYNX OROPHARYNX LARYNGOPHARYNX Extends from basilar part of occipital bone of skull to origin of the esophagus (lower part of cricoid cartilage/ C6 vertebra) 12-15cm long Widest-hyoid bone[5cm] Narrowest- pharyngo - oesophageal jn [1.5cm] DEVELOPMENT-cranial most part of foregut

16. NASOPHARYNX

17. OROPHARYNX Oropharyngeal isthmus Palatine tonsils

18. Blood supply-Tonsils Tonsillar branch of facial artery Twigs from lingual,ascending palatine,ascending phary and maxillary arteries Venous drainage- venae comitantes of tonsillar br of facial artery,paratonsillar vein

19. Nerve supply -Tonsils Threefold sensory nerve supply Glossopharyngeal nerve via pharyngeal plexus Posterior palatine branch of maxillary nerve Lingual branch of mandibular nerve Infiltration anesthesia of tonsils is more practicable

20. Pharynx- clinical In anesthesia/ unconscious patient 1. Relaxation of jaw muscles and the tongue falling back causes obstructed airway 2. Nasal airway blocked by falling back of soft palate LARYNGEAL MASK AIRWAY

21. LMA

22. Laryngopharynx Tip of epiglottis to lower border of cricoid cartilage/C6

23. PIRIFORM FOSSA Foreign body Internal branch of superior laryngeal N Local anesthetics to the surface of piriform fossa on wool balls - anaesthesia of the larynx above VC

24. MUSCLES OF PHARYNX 1.Superior constrictor 2.Middle constrictor 3.Inferior constrictor 4.Stylopharyngeus 5.Salphingopharyngeus 6.Palatopharyngeus

25. LARYNX Protective valve Articulating cartilages C3-C6 vertebra (adults) C3-C4(neonate)

26. THYROID CARTILAGES

27. Thyroid Cartilage Shield like- 2 laminae, open posteriorly, angulated anteriorly Adams apple-Angulation more acute in males Superior and inferior horns Shield larynx from injury and provide an attachment to vocal cords

28. Cricoid Cartilage Signet ring shaped Only part of cartilagenous framework that forms continuous 360 degree ring

29. Arytenoids Pyramidal in shape, paired cartilages Base articulated with cricoid PCA & LCA muscles attach on lateral muscular process

30. Epiglottis Thin leaf shaped fibro-cartilage, situated in midline Lower tapering end-back of thyroid cartilage by thyro epiglottic ligament Upper free end broad & rounded, projects up behind base of tongue –overhangs inlet of larynx

31. Valleys on either side of median glosso epiglottic fold is called valleculae Neonate – epiglottis is more deeply furrowed at its free end Long, deeply grooved, floppy epiglottis protects nasotracheal passage during swallowing Corniculate-small nodule at apex of arytenoid Cuneiform-flake of cartilage within margin of aryepiglottic fold

32. Laryngeal ligaments EXTRINSIC Thyrohyoid membrane- pierced by superior laryngeal vessels & internal laryngeal nerve Crico tracheal membrane Cricothyroid membrane- intratracheal injection -Emergency cricothyrotomy INTRINSIC Quadrangular cricovocal membrane

33. Lower free border of quadrangular membrane –vestibular folds/false cord Upper free border of cricovocal membrane- vocal folds/true cord

34. cricothyroidotomy

35. MUSCLES OF LARYNX EXTRINSIC AND INTRINSIC GROUP OF MUSCLES EXTRINSIC Sternothyroid Thyrohyoid Inferior constrictor of pharynx Stylopharyngeus & palatopharyngeus

36. EXTRINSIC MUSCLES origin insertion Nerve supply function sternothyroid Posterior aspect of manubrium Oblique line on lateral surface of thyroid lamina Ansa glossi Depresses larynx thyrohyoid Oblique line of thyroid lamina Inf border of greater horn of hyoid Fibres of c1 conveyed through hypoglossal Elevates larynx Inferior constrictor Oblique line of thyroid lamina Median raphe Accessory RLN &SLN Constrictor of pharynx

37. INTRINSIC MUSCLES Origin insertion function abducts PCA Post aspect of lamina of cricoid Post aspect of muscular process of arytenoid Abducts cord by ext rotation of arytenoid LCA Superior border of arch of cricoid Lateral aspect arytenoid Adducts cord by int rotation of arytenoids Thyroarytenoid Post aspect of juncn of lamina of thyroid cartilage Arytenoid cartilage- anterolateral aspect Shortens and relaxes vc cricothyroid Ant part of outer aspect of arch of cricoid cart Inf border of lamina of thy cartliage & ant face of inf cornu Only tensor of cord

38. Interarytenoid Only unpaired muscle of larynx Close glottis particularly postereriorly Made up of transverse & oblique fibres Vocalis Some muscle fibres of deep aspect of thyroarytenoid that are inserted into VC Adjusting mechanism to tension of cord

39. Abductors of cords- PCA Adductors of the cords- LCA, Interarytenoides Tensor of VC- Cricothyroid only intrinsic muscle lies outside cartilagenous framework Regulators of cord tension cricothyroid(tensor) thyroarytenoid( relaxor ) vocalis(fine adjustment[relax])

40. Blood supply External carotid ↓ superior thyroid artery ↓ Superior laryngeal artery Accompanies internal branch of superior laryngeal nerve Subclavian artery ↓ Thyrocervical trunk ↓ Inferior thyroid branch ↓ Inferior laryngeal artery Accompanies Recurrent laryngeal nerve

41. Lymphatic drainage Supraglottic area-upper deep cervical LN Infraglottic area-lower deep cevical LN Ant part of lower larynx-small prelaryngeal & pretracheal nodes Vocal cord-no lymphatics

42. NERVE SUPPLY OF LARYNX

43. 00

44. SENSORY -above VC- internal laryngeal nerve below VC- recurent laryngeal nerve MOTOR -all intrinsic muscles by recurrent laryngeal nerve except cricothyroid Cricothyroid -external laryngeal nerve Arytenoideus transversus muscle-Recurrent laryngeal nerve and internal laryngeal N

45. LARYNGEAL CAVITY

46. Vocal cord Pearly white folds of mucous membrane Angle of thyroid cartilage to vocal process of arytenoid Narrowest part of laryngeal cavity Stratified squamous epithelium[larynx-ciliated columnar epithelium] No submucosa with blood vessels No mucous glands

47. Vocal cord palsies

48. Pure abductor palsy left Phonation-both cords meet in midline

49. Abductor & adductor palsy-left Phonation-right cord crosses midline in an attempt to meet its opposite side

50. B/L recurrent N palsy Partial palsy VC lie in midline Airway reduced Resp obstruction

51. B/L palsy of RLN & ELN VC no longer tensed AP diameter reduced True cadaveric position a/w paralysis of cricothyroid

52. Laryngoscopic anatomy Flexion of neck brings the axis of pharynx& larynx in one plane Extension at atlanto occipital joint brings oropharynx, larynx & mouth in one plane

53. LARYNGOSCOPIC VIEW

54. Difficult intubation

55. Mallampati score

56. LARYNX- Paediatric C4-C5 FUNNEL SHAPED

57. PAEDIATRIC ADULT

58. TRACHEOBRONCHIAL TREE ANATOMY AND CLINICALAPPLICAT ONS

59. TRACHEO BRONCHIAL TREE Trachea Principal / Primary bronchus Lobar /Sec. bronchus Segmental/tertiary bronchus (10 in each side) Terminal bronchiole Respiratory bronchiole Alveoli

60. TRACHEA EXTEND FROM LOWER END OF CRICOID CARTILAGE TO TRACHEAL BIFURCATION MEMBRANOCARTILAGINOUS TUBE 15 CM LONG IN ADULTS Children-4 cm length 3mm diameter

61. TRACHEA Cartilages are joined vertically by fibroelastic tissue and closed posteriorly by non striated trachealis muscle. In children : smaller, deeply placed and more mobile.

62. TRACHEA CARINA: keel-shaped cartilage seen as sagittal ridge bronchoscopically . Flattened sharp edge means: enlargement of the hilar lymph nodes or gross distortion of the pulmonary anatomy by fibrosis, tumour or other pathology

63. Bronchoscopic view of trachea Trachealis muscle carina U shaped cartilage

64. TRACHEA BLOOD SUPPLY: INFERIOR THYROID ARTERIES LYMPHATIC DRAINAGE :DEEP CERVICAL PRETRACHEAL NERVE SUPPLY : VAGUS, RECURRENT LARYNGEAL N SYMPATHETIC SUPPLY FROM MIDDLE CERVICAL GANGLION

65. CLINICAL APPLICATION TRACHEOSTOMY 2nd to the 4 th rings are covered by the isthmus of the thyroid So in tracheostomy the lower tracheal rings are chosen to save thyroid tissue First tracheal ring is spared because cricoid rests on it.

66. CLINICAL APPLICATION Thyroidea ima artery , ascending from the arch of the aorta or from the brachiocephalic artery if present, erosion of the tracheal wall by a tracheostomy tube may cause sudden profuse haemorrhage in the lower part of neck . Posteriorly esophagus with RLN on either side in a groove between trachea and esophagus

67. CLINICAL APPLICATION TRACHEA MOVES WITH RESPIRATION : Adult-tip of orotracheal tube moves an average of 2 cm with flexion and with extension of the neck. infants and children-more critical: displacement of even 1 cm can move the tube above the cords or below the carina.

68. CLINICAL APPLICATION ENDOTRACHEAL TUBE FIXATION AND CUFF PRESSURE: ETT advanced until the cuff is about 2 cm distal to the vocal cords as proximal positions may cause cuff leaks and pressure on the recurrent laryngeal nerve. Cuff pressure is then adjusted to 25 to 30 cm H 2 O . abdominal insufflation can shift the carina cephalad and convert an acceptable location to an endobronchial one

69. CLINICAL APPLICATION In infants the brachiocephalic artery is higher and crosses the trachea just as it descends behind the suprasternal notch. The left brachiocephalic vein may project upwards into the neck to form an anterior relation of the cervical trachea-a frightening encounter if found tensely distended with blood when performing a tracheotomy on an asphyxiating baby. In children up to the age of 2 years, the thymus is large and lies in front of the lower part of the cervical trachea.

70. Right main bronchus shorter, wider and more vertically placed shorter because it gives off its upper lobe bronchus sooner(after a course of only 2.5 cm) wider because it supplies the larger lung More vertically placed at 25°(45 deg in children)

71. Right main bronchus 1.3 cm wide Right pulmonary artery is first below and then in front of right bronchus, and azygos vein arches over it. Right upper (2.5 cm from carina ,at 90 deg)and middle lobe bronchi divide from RMB The main channel becomes the right lower lobe bronchus.

72. Left main bronchus 5 cm long. 1.1 cm wide 45 degress to trachea(same in children) passes under the aortic arch, in front of the oesophagus, thoracic duct and descending aorta, and has the left pulmonary artery lying first above and then in front of it.

73. Left main bronchus Branches into left upper lobe and the lingual. it continues on as the left lower lobe bronchus.

74. CLINICAL APPLICATION- Endobronchial tubes right-sided endobronchial tubes have an orifice in the lateral surface of the tube that coincides with the opening of the right upper lobe No special arrangement in left endobronchial tube Increased chance of Right endobronchial intubation in adults if tube is pushed in more(either of the sides in children.)

75. Innervation of bronchial tree Sympathetic and parasympathetic innervation Sympathetic nerve fibers: T1 – T5 along with branches from inferior cervical ganglion and some from middle cervical ganglion Parasympathetic: vagus nerve

76. BRONCHIOLES Typically 1 mm in diameter Devoid of cartilaginous support and have the highest proportion of smooth muscle in the wall. Terminal bronchiole is the last airway component that does not participate in gas exchange.

77. The respiratory bronchiole , which follows the terminal bronchiole, is the first site in tracheobronchial tree where gas exchange occurs.

78. Respiratory bronchioles and alveolar ducts In adults, two or three generations of respiratory bronchioles lead to alveolar ducts, of which there are four to five generations , each with multiple openings into alveolar sacs. The final divisions of alveolar ducts terminate in alveolar sacs that open into alveolar clusters.

79. Alveolar wall consists of : a thin capillary epithelial cell basement membrane pulmonary capillary endothelial cell surfactant lining layer Alveolar macrophages-last line of defence in alveoli with its enzymes Pores of kohn -holes in alveolar wall provide collateral ventilation

80. Alveolar capillary membrane 1)Alveolar epithelium 95%-epithelial type I cells( agranular pneumocytes)- gas exchange Epithelial type II cells(granular pneumocytes) 2)Basement membrane of alveolar epithelium 3)Basement membrane of capillary endothelium 4)Capillary endothelium -

81. Alveolar capillary membrane The alveolar-capillary membrane has two primary functions: Transport of respiratory gases (oxygen and carbon dioxide) The production of a wide variety of local and humoral substances.

82. Alveolar capillary membrane TYPEI CELLS : cover ~80% of the alveolar surface. Contain flattened nuclei and extremely thin cytoplasmic extensions that provide the surface for gas exchange. highly differentiated and metabolically limited damaged severely in ALI and ARDS type II cells replicate and modify to form new type I cells.

83. Alveolar capillary membrane TYPE II interspersed among type I cells, primarily at alveolar– septal junctions. polygonal cells with vast metabolic and enzymatic activity and manufacture surfactant. modulates local electrolyte balance, as well as endothelial and lymphatic cell functions.

84. EPITHELIUM

85. BRONCHOPULMONARY SEGMENTS The anatomic, functional, and surgical units of lung is known as bronchopulmonary segments. Approximately 10 bronchopulmonary segments in each lung Each of pyramid shaped, with its apex towards the lung root Each segment has its own separate artery (branch of pulmonary artery) segmental bronchus, autonomic nerves and lymph vessels. Segmental veins runs in the connective tissue between adjacent bps. Thus BPS is not bronchovascular segment as it does not have its own vein.

86. Postural drainage Also called as pulmonary toilet Positioning the patient so that retained secretions in the bronchopulmonary segments can be drained by gravity out of the lungs Positioning the patient is important to allow the bronchi of each BPS to be vertical so that fluid inside the bronchus will move toward the main stem bronchi and out of the lung.

87. THANK YOU