Glossary of GA-822-06

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What is the clinical significance of the sternal angle?
-most important clinical landmark on anterior chest wall
-the second rib attaches here
-gives landmark to count intercostal spaces
Costodiaphragmatic Recess
-in the most inferior part of the pleural sac and in reference to TWO specific parts of the parietal pleura (costal and diaphragmatic)
What will happen if air is introduced in the pleural sac existing between the visceral and parietal pleura of the lungs?
-you will "drop a lung"
-lung will be compressed to about the size of a fist
Pleural Reflection
-when one part of the parietal pleura turns abruptly towards another direction as it covers another part of the walls of the pulmonary cavity
-covers the apex of the lung
-cervical portion of the parietal pleura
-lies 3 cm superior to the medial 1/3 of the clavicle
Where do the two pleural sacs approach each other?
-between ribs 2-4
Cardiac Notch of the Pleura
-deviation on left side at level of 4th costal cartilage
Where does the pleaura dip inferior to the rib cage?
-right infrasternal angle
-if a surgeon enters the right infrasternal angle, could cut pleura and introduce air, bacteria, blood, etc into pleural sac
What levels do the pleura and lungs extend to in the mid-clavicular line?
Pleura = level of 8th rib
Lungs = level of 6th rib/costal cartilage
Where do the lungs and pleura lie in the mid-axillary line?
Pleura = level of rib 10
Lungs = 8th intercostal space
Where would you do a thoracocentesis in the mid-axillary line?
-at level of 9th rib in between 8th and 9th rib
-here you are below the lungs and still in the costodiaphragmatic recess
-mid-axillary line is a commonly used landmark for thoracocentesis
Where do the lungs and pleura lie in the scapular line?
Pleura = 12th rib
Lungs = 10th intercostal space
Where are the lungs closest to each other?
-between ribs 2 and 4 anteriorly
Horizontal Fissure
-divides the superior lobe into the superior lobe proper and middle lobe on right lung
-lies at level of 4th rib deep to 4th costal cartilage
-considered an evolving trait in human species and fading out of right lung
Oblique Fissure
-passes to the costal margin at the level of the 6th costal-chondral junction
-divides each lung into superior and inferior lobe
-similar to thoracocentesis
-aspirate fluid from pericardial sac
-fluid may be reached directly through the anterior thoracic wall without going through the pleura due to the cardiac notch
Internal Thoracic Artery
-branch off subclavian
-descends down along the anterior part of the thoracic cage posterior to the sternum, down the the diaphragm where it terminates into the musculophrenic artery and superior epigastric artery
Superior Epigastric Artery
-branch of the Internal Thoracic Artery
-extends from the diaphragm to the rectus sheath
-extends inferiorly
-prevented from collapsing by cartilaginous rings (18-20) which are slightly opened posteriorly
-posteriorly, trachea has smooth muscle and mucus membrane
-likes anterior to esophagus
What happens if you pass an intubation tube too far posteriorly in the trachea?
-you can puncture the posterior wall and enter the anterior side of the esophagus and introduce air into the stomach
-angle between the parts of the main bronchi
-indicates bifurcation
-few cough reflex/nerve fibers inferior to carina
What can cause an enlargement of the carina?
-cancer forming a blockage of the right main bronchus
-on left lung only
-tongue like projection analagous to middle lobe of right lung
3 Surfaces of the Lung
1. Costal/Lateral (against ribs)
2. Medial
3. Diaphragmatic (lying against diaphragm)
-concavity where structures
-depression in the medial surface of the lung where structures comprising the root of the lung enter and leave
Structures of the Root of the Lung
1. Bronchus
2. Pulmonary artery
3. Pulmonary vein
Borders of the Lungs
1. Anterior- sharp and helps form cardiac notch
2. Posterior- rounded
3. Inferior- sharp
Base of Lung
-same as diaphragmatic surface
-going through neck, taking scope down into region of lung root
Bronchopulmonary Segments
-smallest portion of lung that can be resected
-have own arterial supply which follows tertiary bronchi in middle of each BP segment
-right lung has 10
-left lung has 10 which are usually fused into 8
BP Segments for upper lobe of right lung
BP segments for middle lobe of right lung
BP segments for inferior lobe of right lung
-anterior basal
-posterior basal
-medial basal
-lateral basal
BP segments for upper lobe of left lung
BP segments for lingula of left lung
-superior lingular
-inferior lingular
BP segments for inferior lobe of left lung
-anterior basal
-posterior basal
-medial basal
-lateral basal
-disease resulting in air blowing out of alveoli
-surface of lung will look transparent because you are looking in the alveoli
Bronchial Arteries
-usually 2 on left arising from aorta
-1 on right arising from 3rd posterior intercostal artery
-pass through center of BP segment
-supply bronchi and connective lung tissue
5 Tracheobronchial Lymph Nodes
1. Intrapulmonary/pulmonary Nodes
2. Hilar Lymph Nodes
3. Inferior Tracheobronchial/Carinal Nodes
4. Superior Tracheobronchial Nodes
5. Paratracheal Tracheobronchial Nodes
Intrapulmonary/Pulmonary Lymph Nodes
-inside the lobes
Hilar Lymph Nodes
-right at hilum
-downstream of intrapulmonary lymph nodes
Inferior Tracheobronchial/Carinal Lymph Nodes
-if these are enlarged can deviate carina
-can be seen on bronchoscope
Course of Lymph drainage in Lungs
-lymph in pulmonary nodes drains into hilar lymph nodes
-hilar lymph nodes drain into inferior and superior tracheobronchial lymph nodes
-these drain into paratracheal lymph nodes
-these proceed superiorly to the bronchomediastinal lymph trunk
-bronchomediastinal lymph trunk drains into the junction of the IJV and right subclavian on the right side
-on the left it also drains into the junction of the IJV and left subclavian
Right Lympatic Duct
-drains upper 1/4 of body
-receives subclavian trunk from upper limb
-receives jugular trunk from head and neck and the bronchomediastinal trunk
-all three trunks combine to form the right lymphatic duct
Left Lymphatic Duct
-comprable to right lymphatic duct
-largest of the body
-drains the remaining 3/4 of body surface
Where does 55% of lung cancer occur?
upper right lobe
What is the second most common site for primary carcinogenic lung cancer?
upper left lobe
Cardiac Plexus
-has subdivisions as pulmonary plexus and esophageal plexus
-has parasympathetic and sympathetic fibers
Parasympathetic fibers from vagus
-dilate blood vessels and secretomotor
Sympathetic Fibers in lungs
-dilate air passages
-constrict blood vessels
-inhibit glands
Vagus Nerve
-presynaptic fiber arises in brain stem
-synapse occurs in pulmonary plexus
-fibers proceed to bronchial tree
Synpathetic innervation of thoracic viscera
-fibers originate in gray matter
-axon proceeds out, running in white ramus communicans to sympathetic trunk
-fibers synapse
-post ganglionic fibers run directly to heart with subdivisions in lungs and esophagus
-also called THORACIC SPLANCHNIC NERVES and cardiopulmonary nerves
Pulmonary Ligament
-communication between visceral pleura and parietal pleura at root of lung
-covers structures that form the root of the lung
-sleeve is enlarged superiorly to cover over and surround the structures forming the root that enter the lung and hilum
Cervical Rib
-present in 1% of people
-can elevate inferior trunk of brachial plexus and cause problems
Herpes Zoster
-lies dormant in dorsal root ganglia then all of a sudden disseminates itself out to the intercostal nerve (ventral primary ramus) and can go to cutaneous branches
-develop pustules and pain in regions of cutaneous nerves
Pleural Cavity
-potential space between visceral and parietal pleura
Which pleura is insensitive to pain and why?
-visceral, due to autonomic innervation
Tension Pneumothorax
-spontaneously air rushes into pleaural sac
-air builds up and there is no release for it
-lung collapses
-occludes veins and arteries
-air can be withdrawn using 2nd intercostal space
-accumulation of inflammatory exudate within pleural cavity
-pain is referred to parietal pleura to cutaneous distribution of intercostal nerve
-accumulation of blood in pleural cavity
-usually result of trauma but can be due to lung disease
What innervates the parietal viscera?
-upper 12 intercostal nerves
What do the lower 6 intercostal nerves supply in addition to the parietal pleura?
-skin of anterior abdominal wall
Where can pain from pleurisy be referred to?
-anterior abdominal wall
-done to remove excess fluid or take a sample
-insert needle along superior border of rib to avoid damaging intercostal nerve that is on the inferior border
-4th or 5th intercostal space in mid-axillary line
What abdominal organ must you be careful to avoid damaging during thoracocentesis?
Layers a Needle must go through in Thoracocentesis
1. skin
2. superficial fascia
3. deep fascia
4. superficial thoracic muscles
5. ribs
6. external intercostal
7. interal intercostal
8. VAN
9. innermost intercostal
10. endothoracic fascia
11. parietal pleura
12. pleural cavity
13. visceral pleura
14. lung
What procedure is done to manage pain of thoracocentesis?
-intercostal nerve block

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