Respiratory%20system%20II.

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Respiratory systemII.
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Anatomical division

• upper respiratory tract
• nasal cavity
• paranasal cavities
• nasopharynx
• lower respiratory tract
• larynx
• trachea
• tracheobronchial tree
• respiratory compartment

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Anatomical division
Surgical division

• upper respiratory tract
• nasal cavity
• paranasal cavities
• nasopharynx
• larynx
• lower respiratory tract
• border apertura thoracis sup.
• trachea
• tracheobronchial tree
• respiratory compartment

• upper respiratory tract
• nasal cavity
• paranasal cavities
• nasopharynx
• lower respiratory tract
• larynx
• trachea
• tracheobronchial tree
• respiratory compartment

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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

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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

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TRACHEA
Pars cervicalis
Pars thoracica
Cartilagines tracheales
M. trachealis
Ligg. anularia / trachealia
Paries membranaceus
Bifurcatio tracheae
Carina tracheae
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Endoscopy view of trachea
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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

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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)

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Tracheotomy

• sagittal 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

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• coniotomy
• upper tracheotomy
• lower tracheotomy

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Tracheotomy risks

• bleeding from
• plexus thyroideus impar
• a. thyroidea ima (2)
• arcus venosus jugularis
• lobus pyramidalis glandulae thyroideae (40)

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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

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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 12 connected, 78 connected in 90
• exception 6th bronchus segmentalis of both sides
  branches in trichotomic way!

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Tracheobronchial tree (Arbor bronchialis)

• bronchi 4th order (bronchus subsegmentalis)
• b ventral, a dorsal
• bronchi 5th order ii ventral, i dorzal
• bronchi 6th order ß ventral, a 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)

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Bronchi (Bronchi)

• tunica mucosa
• epithelium of respiratory tract
• pseudostratified ? columnar with cilia
• seromucous glands
• tunica fibromusculocartilaginea
• cartilages have irregular shape (more peripheraly
  disappear)
• smooth muscle spiral (more peripheraly
  increases)
• nodes of lymphoid tissue at the branching

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Bronchioli (Bronchioli)

• caliber lt 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

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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

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RIGHT LUNG LEFT LUNG
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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)
• III fused, VII missing in 90

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HILUM PULMONIS Left lung
Right lung
B A V
A B V
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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

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Segments right lung (apalmsmalp) left lung
(apasismalp)
Abb. Segmentum No. of segment Lobe
AP apico-posterious I II upper
A anterius III upper
S lingulare superius IV upper
I lingulare inferius V upper
S superius VI lower
M basale mediale VII lower
A basale anterius VIII lower
L basale laterale IX lower
P basale posterius X lower
Abb. Segmentum No. of segment Lobe
A apicale I upper
P posterius II upper
A anterius III upper
L laterale IV middle
M mediale V middle
S superius VI lower
M basale mediale VII lower
A basale anterius VIII lower
L basale laterale IX lower
P basale posterius X lower
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Lung segments
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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
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Segmenta bronchopulmonalia
Pulmo sinister, lobus superior
Segmentum apicoposterius S III
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
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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 lt 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

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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

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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

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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 III, III) ? n.l. tracheobronchiales
  sup. dx. ? truncus bronchomediastinalis dx. ?
  angulus venosus dx. ? v. brachiocephalica dx.
• III, III segments on the left directly into
  n.l. tracheobronchiales sin. ? truncus
  bronchomediastinalis sin. ? ductus thoracicus ?
  angulus venosus sin. ? v. brachiocephalica sin.

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Lungs innervation

• nn. vagi both sides
• viscerosensory autonomic parasympathetic
  stimuli
• truncus sympathicus
• autonomic sympathetic stimuli

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Tracheobronchial tree (Arbor alveolaris)

• dichotomic branching
• from bronchioli respiratorii onwards
• 17th-23rd order
• functionally respiratory compartment

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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)

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Respiratory bronchioliBronchioli respiratorii

• diameter lt 0,3 mm
• simple ciliated cuboidal epithelium
• branching of pulmonary alveoli
• continue into alveolar ducts

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Lung alveoliAlveoli pulmonis

• 200 µm size, polyedric, thin-walled
• alveolar mucosa respiratory epithelium
• alveolar septum
• alveolar pores (Kohn)

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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)

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Interalveolar septumSeptum 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

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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 ?)

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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

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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)

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Lungs clinical examination

• inspection, percussion, auscultation, palpation
• X-ray, CT
• bronchoscopy (rigid, flexibile)
• bronchography
• spirometry (vital capacity of lungs)

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A-P and lateral X-ray of lungs
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CTof thorax
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Bronchogram
Bronchogram
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Lungs clinical units

• atelectasis
• embolia
• bronchiectasis
• fibrosis
• lung oedema
• RDS (IRDS), ARDS
• emphysema
• tumors, inflammations (e.g. TBC)

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Kartagener syndrome

• missing movement of cilia
• molecular defect in ciliar mobility apparatus
• chronic pyogenic rhinitis and sinusitis
• bronchiectasis

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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

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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

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Small cell lung carcinoma
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Pleura
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Parietal visceral pleuraPleura parietalis et
visceralis

• serous membrane
• mesothelium (simpler flat)
• tunica serosa
• tela subserosa
• pleura visceralis
• pleura parietalis
• pars costalis, diaphragmatica, mediastinalis

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Pleura
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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)

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Pleura
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Left pneumothorax
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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)

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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 !!!

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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

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Projection of lungs and pleura
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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

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Mediastinum

• anatomical division
• upper
• lower (anterior, middle, posterior)
• surgical division (many ?) e.g.
• anterior
• posterior

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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
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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
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Mediastinum posterius