Respiratory systemRespiratory systemII.II.

Anatomical divisionAnatomical division

• upper respiratory tract– nasal cavity– paranasal cavities– nasopharynx

• lower respiratory tract– larynx– trachea– tracheobronchial tree– respiratory compartment

Anatomical Anatomical divisiondivision

• upper respiratory tract– nasal cavity– paranasal cavities– nasopharynx

• lower respiratory tract– larynx– trachea– tracheobronchial tree– respiratory compartment

Surgical divisionSurgical division

• upper respiratory tract– nasal cavity– paranasal cavities– nasopharynx– larynx

• lower respiratory tractborder: apertura thoracis sup.

– trachea– tracheobronchial tree– respiratory compartment

General structure of respiratory system wallGeneral 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

TracheaTrachea

• 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

TRACHEA

Pars cervicalis

Pars thoracica

Cartilagines tracheales

M. trachealis

Ligg. anularia / trachealia

Paries membranaceus

Bifurcatio tracheae

Carina tracheae

Endoscopy view of tracheaEndoscopy view of trachea

Trachea – supplyTrachea – 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

Coniotomy (coniopuncture)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%)

TracheotomyTracheotomysagittal 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

• coniotomy

• upper tracheotomy

• lower tracheotomy

Tracheotomy – risks

bleeding from:

• plexus thyroideus impar

• a. thyroidea ima (2%)

• arcus venosus jugularis

• lobus pyramidalis glandulae thyroideae (40%)

Trachea – wall structureTrachea – 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

Tracheobronchial tree (Tracheobronchial tree (Arbor bronchialisArbor 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: 1+2 connected, 7+8 connected in 90%• exception: 6th bronchus segmentalis of both sides

branches in trichotomic way!

Tracheobronchial tree (Tracheobronchial tree (Arbor bronchialisArbor bronchialis))

• bronchi 4th order (bronchus subsegmentalis): b = ventral, a = dorsal• bronchi 5th order: ii = ventral, i = dorzal• bronchi 6th order: β = ventral, α = 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)

Bronchi (Bronchi (BronchiBronchi))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

Bronchioli (Bronchioli)

• caliber < 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

Lungs (Lungs (PulmoPulmo))

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

RIGHT LUNG LEFT LUNG

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)

• I+II fused, VII missing in 90%

HILUM PULMONISHILUM PULMONISLeft lung Right lung

BAV

ABV

Lungs – impressionsLungs – 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

SegmentsSegments right lung (apalmsmalp) left lung (apasismalp)

Abb. Segmentum No. of segment

Lobe

AP apico-posterious

I + II upper

A anterius III

S lingulare superius

IV

I lingulare inferius

V

S superius VI lower

M basale mediale

VII

A basale anterius

VIII

L basale laterale

IX

P basale posterius

X

Abb. Segmentum No. of segment

Lobe

A apicale I upper

P posterius II

A anterius III

L laterale IV middle

M mediale V

S superius VI lower

M basale mediale

VII

A basale anterius

VIII

L basale laterale

IX

P basale posterius

X

Lung segmentsLung segments

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]

Segmenta bronchopulmonalia

Pulmo sinister, lobus superior

Segmentum apicoposterius [S I+II]

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]

Blood supply of lungs – functional circuitBlood 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 < 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

http://www.biosbcc.net/doohan/sample/index.htm

BloodBlood supply of lungs supply of lungs functional circuit functional circuit

• arterio-venous anastomoses

• arterio-arterial anastomoses

• veno-venous anastomoses

• during hypoxia fastly growing arterial smooth muscle → hypertrophy of right ventricle

Vascular supply of lungs – nutritive circuitVascular 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

Lungs – lymph drainageLungs – lymph drainage• superficial subpleural plexus• deep plexus around bronchi and vesselsLung 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 I+II, III) → n.l. tracheobronchiales sup. dx. → truncus bronchomediastinalis dx. → angulus venosus dx. → v. brachiocephalica dx.

I+II, III segments on the left – directly into n.l. tracheobronchiales sin. → truncus bronchomediastinalis sin. → ductus thoracicus → angulus venosus sin. → v. brachiocephalica sin.

Lungs – innervationLungs – innervation

• nn. vagi both sides

viscerosensory + autonomic parasympathetic stimuli

• truncus sympathicus

autonomic sympathetic stimuli

Tracheobronchial tree (Tracheobronchial tree (Arbor alveolarisArbor alveolaris))

• dichotomic branching

• from bronchioli respiratorii onwards

• 17th-23rd order

• functionally respiratory compartment

Tracheobronchial tree (Tracheobronchial tree (Arbor alveolarisArbor 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)

Respiratory bronchioliRespiratory bronchioliBronchioli respiratoriiBronchioli respiratorii

• diameter < 0,3 mm

• simple ciliated cuboidal epithelium

• branching of pulmonary alveoli

• continue into alveolar ducts

Lung alveoliLung alveoliAlveoli pulmonisAlveoli pulmonis

• 200 μm size, polyedric, thin-walled

• alveolar mucosa = respiratory epithelium

• alveolar septum

• alveolar pores (Kohn)

Alveolar mucosaAlveolar 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)

Interalveolar septumInteralveolar septumSeptum interalveolareSeptum 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

Blood – air barrierBlood – air barrier((Claustrum aerosanguineumClaustrum 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 )

Surfactant (Surfactant (SurfactantumSurfactantum))(alveolar „lining complex“)(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

Defense mechanismsDefense 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)

Lungs – clinical examinationLungs – clinical examination

• inspection, percussion, auscultation, palpation

• X-ray, CT

• bronchoscopy (rigid, flexibile)

• bronchography

• spirometry (vital capacity of lungs)

A-P and A-P and laterallateral X-ray of lungs X-ray of lungs

CTCTof of

thoraxthorax

Bronchogram

Bronchogram

Lungs – clinical unitsLungs – clinical units

• atelectasis

• embolia

• bronchiectasis

• fibrosis

• lung oedema

• RDS (IRDS), ARDS

• emphysema

• tumors, inflammations (e.g. TBC)

Kartagener syndromeKartagener syndrome

• missing movement of cilia

• molecular defect in ciliar mobility apparatus

• chronic pyogenic rhinitis and sinusitis

• bronchiectasis

Cystic fibrosis (muCystic fibrosis (muccoviscidosis)oviscidosis)

• 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

Lung tumorsLung 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

SmallSmall cell lung carcinomacell lung carcinoma

PleuraPleura

Parietal + visceralParietal + visceral pleura pleuraPleuraPleura parietalis et visceralis parietalis et visceralis

• serous membrane– mesothelium (simpler flat)– tunica serosa– tela subserosa

• pleura visceralis

• pleura parietalis– pars costalis, diaphragmatica, mediastinalis

PleuraPleura

PleuraPleura

• 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)

PleuraPleura

Left pneumothoraxLeft pneumothorax

Parietal pleura – supplyParietal pleura – supplyArteries:• a. subclavia → a. thoracica interna → a.

musculophrenica + aa. intercostales ant.• aorta thoracica → aa. intercostales post. Veins: thoracic wall veinsLymph: n.l. intercostales, parasternales,

diaphragmatici, mediastinales posterioresNerves:• nn. intercostales (pleura costalis + peripheral

pleura diaphragmatica)• n. phrenicus (pleura mediastinalis + central pleura

diaphragmatica)

Pleura visceralis – supplyPleura 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 !!!

Projection of pleura and lungsProjection 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

Projection of Projection of lungs and lungs and

pleurapleura

Respiratory musclesRespiratory 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

MediastinumMediastinum

• anatomical division:– upper– lower (anterior, middle, posterior)

• surgical division (many ): e.g.– anterior– posterior

Mediastinum superiusstructures 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

Mediastinum inferiusMediastinum inferiusMediastinum 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

Mediastinum Mediastinum posteriusposterius