Lower Respiratory Tract Anatomy. Thoracic wall arterial supply: Posterior intercostal arteries ...
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Transcript of Lower Respiratory Tract Anatomy. Thoracic wall arterial supply: Posterior intercostal arteries ...
Lower Respiratory Tract Anatomy
Thoracic wall arterial supply:
Posterior intercostal arteries
Descending aorta
Anterior intercostal arteries
Internal thoracic artery
Importance of anastomoses?
Collateral circulation to get around blockage e.g. aortic coarctation
See widened costal margins on CXR (dilated intercostal arteries)
Thoracic wall venous drainage
Intercostal veins ultimately drain into:
Hemiazygous vein
Accessory hemiazygous vein
Azygous vein
Internal thoracic veins
Drain into:
Brachiocephalic vein (upper spaces)
SVC
Azygous vein
Intercostal veins
Hemiazygous vein
Accessory hemiazygous
vein
Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy
2cc
6cc
6rib MCL8 rib MAL
Apex sits ~2cm above medial 1/3 of clavicle
Horizontal fissure:4thcc horizontally back to oblique fissure
Oblique Fissure: T3 Spinous Process to 6th cc anteriorly
Lung Surface Markings
Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy
8 rib MCL
10 rib MAL
6cc
Pleural Markings
Marks the point of reflection of parietal pleura from the thoracic wall.
Costodiaphragmatic recess = region between lung and pleura.
Liver biopsy…patient inhales or exhales?
Exhale! Extend the gap between the lungs + pleura.
Reduces risk of complications.
Trachea originates at what vertebral level?
C6 (continuation of cricoid cartilage)
Bifurcates at what vertebral level?
T4 / T5
More likely to aspirate into which bronchus? Why?
Right…more vertical, foreign body / gastric contents more likely to fall this way.
Why’re you worried about a flattened angle at the carina?
Lymph nodes inferior to carina…consider lung tumour!
What three things does the smallest functional unit of the lungs need (bronchopulmonary segments)?
Air supply.
Venous drainage.
Arterial supply.
Each segment is separated by fibrous tissue.
Pulmonary veins:
Run between segments.
Oxygenated blood.
Pulmonary artery:
Run with bronchi + bronchioles (need to for gas exchange)!
Deoxygenated blood.
Pulmonary vein
Pulmonary artery
Segmental 3° bronchus
Where does the diaphragm attach?
Diaphragm is a muscular & tendinous structure that domes into the thoracic cavity
What is the diaphragm?
The Diaphragm + External intercostals + Scalenes/ sternocleidomastoid
Tom Grant is 26 year old man with two lungs. What provides the driving force for inspiration when Tom is breathing?
Diaphragm attaches to costal margin & ribs 10-12 Diaphragmatic crura attach to
lumbar vertebrae
Central tendinous part for heart
A 35 year old man presents with dyspnoea that is worse on exertion and when lying down. His ECG is normal. He is a non-smoker, his lungs are clear and he has denies any recent trauma or accidents.
a) Angina b) hemi-diaphragmatic paresis c) Chest wall muscle straind) COPDe) Anaemia
The injury has cause him Atelectasis, what is Atelectasis?
- Incomplete expansion of the lungs- Diminishing volume affecting all or part of a lung - Obstructive/ non-obstructive/ postoperative- Obstructive due to obstruction of air flow between trachea and alveoli- Non-obstructive due to loss of contact between visceral and parietal pleura
What nerve supplies the diaphragm?
Diaphragm innervated by phrenic nerve (C3,4,5) for motor and sensoryAdditional sensory innervation on the periphery from intercostal nerves
Which one of these is normal? Why?
What three important structures pass through the diaphragm?
Vena cava thoracic-abdominal aorta oesophagus
Which vertebral level do they pass through the diaphragm?
Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy
Vena Cava – T8
Oesophagus – T10
Descending Aorta – T12
Rosie is 75 year old obese ex-weightlifter with 3 children who experiences burning chest pain after meals. After being encouraged by her husband bob to visit her GP, the GP refers her for a CXR what might they find?
Hiatus herniaHerniation of stomach through the diaphragmatic oesophageal hiatus Mostly asymptomaticGORD most likely complicationMore likely in women who have given birth, obese people, increasing age
Bob prompting Rosie to visit the GP is called sanctioning and is one of the triggers to seek help known as the ‘lay referral’ system. What are 4 other triggers?
Interpersonal crisisSymptoms interfering with personal and/or social relationsInterference with work or physical activity A ‘temporalizing of symptomatology'
Gary Is in a car crash and experiences blunt trauma to this thorax, a decision is made to insert a chest drain. What is the most likely reason the chest drain is inserted in this instance?
Pneumothorax To give a passage for the air inside the pleural cavity to escape
What are additional indications for chest drain use?
HaemothoraxPleural effusionEmpyemaChylothorax (lymphatic effusion due to disruption/ obstruction of the thoracic duct)
Gary is rather spiritual and believes that his life force will be sucked out from his thorax by the chest tube. His spiritualism is one form of lay belief, name 4 others
Personal knowledge The media and the internetReligion Alternative and completmentary medicineFolk law Previous medical encounters
Triangle of safety
What are the surface markings for the triangle of safety
Where is a chest tube inserted?
Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy
Posterior axillary line Anterior axillary line
Nipple line 3RD OR 4TH ICS
LATERAL BORDER OF PEC. MAJOR
ANTERIOR BORDER OF LAT DORSI
NOT ALWAYS ACCURATE
How many lobes do the lungs have?
Right lung has 3 lobes and the left has 2 lobes....although this can vary
What is the left lobes middle lobe called?
Lingual lobe
Gary lost his right middle lobe post-pneumothorax. Now identifying as disabled he became an activist for equality and learned the UK equality act, what does the UK equality act state?
The clinical education fellows at Warwick hospital struck up strong relationships with Gary as they used his lack of a right middle lobe to test auscultation technique on the students. What are the auscultation points of the chest that ensure all lobes are auscultated?
Upper lobes – front of chest – large region to choose from (2/3 ICS)
Right middle lobe – axillary region – 4th ICS
Lower lobes – posteriorly - large region to choose from