2-12
Terms
undefined, object
copy deck
- Most important clinical landmark on the anterior chest wall and why it's important.
-
Sternal angle
1) Locating organs based on which intercostal space
2) Second rib attaches to it - Contents of Thorax
-
1) Two Lateral (Pulmonary) Compartments containing lungs and pulmonary sacs (pleural sacs)
2) Central Compartment - Mediastinum (just an area) - What is the most inferior portion of the pleural sac?
- Costodiaphragmatic Recess
- Phrenic means
- Diaphragm
- What is a pneumothorax?
- air or gas enters the pleural cavity
- What is a pleural reflection?
- Point at which one part of the parietal pleura turns abruptly towards another direction as it covers another part of the wall of pulmonary cavity
- What is the apex of the lung covered by and where is it located?
- Covered by cupola (cervical portion of parietal pleura) and lies 3 cm superior to the medial 1/3 of the clavicle & at neck of rib 1
- Between what ribs do the right and left pleura begin to approach one another?
- 2-4
- What is the problem clinically with the fact that the right and left pleura come so close to one another?
- Pleurisy (inflamation of lung) of one lung can travel to the other lung between ribs 2-4
- What is the cardiac notch?
- A deviation of pleura and lung at the level of the 4th costal cartilage to provide room for the heart.
- In what areas does the pleura drop inferior to the rib cage and what is the importance clinically?
-
Anteriorly - right infrasternal angle (near xyphoid process)
Posteriorly - right and left costovertebral angles below rib 12
If surgeon is doing work in abdominal cavity, might cut the pleura and introduce air/blood/bacteria in these areas. - What is the significance of the mid-axillary line? Where does lung lie at this point?
- Pleura border lies at border of rib 10. Lung lies 2 intercostal spaces superior to rib 10. (mid-axillary line is viewed laterally)
- Where would you perform thoracentesis of the mid axillary line?
- In intercostal space between ribs 8/9 and 9/10
- What is the significance of the scapular line and what does it run along? Where is the lung at this point?
- Pleura border on this side is at rib 12 and lung is two intercostal spaces superior. It runs along the vertebral border of the scapula.
- Where is the horizontal fissure located (rib-wise)?
- On right, at level of 4th rib and deep to 4th costal cartilage
- Where is the oblique fissure located (rib-wise)?
- Passes to costal margin at 6th costal-chondral junction
- What is the clinical importance of cardiac notch?
- Can perform pericardiocentesis of pericardial sac and not pierce pleural sac.
- What does the internal thoracic artery terminate into? What else comes off inferiorly of the ITA and where does it terminate?
- Musculophrenic Artery. Superior Epigastric Artery which extends to the rectus sheath.
- Oblique fissure of lung divides the lungs into __A__ and __B__ lobes
-
A. Superior
B. Inferior - What does the horizontal fissure divide the right lung into? What's going on evolutionarily with this fissure?
- Divides the superior lobe into the superior lobe proper and middle lobe (may be disappearing evolutionarily).
- What prevents the trachea from collapsing?
- Cartilaginous rings that are on the anterior surface of it.
- What are the divisions of the trachea and what do they lead to?
-
Primary Bronchi - go to lungs
Secondary Bronchi (lobar bronchi) - go to lobes
Tertiary divisions - specific parts of the lobes - How many cartilaginous rings surround the trachea, and what is located in the openings of the posterior side?
- 18-20; smooth muscle and mucous membrane
- What is the clinical significance of the lack of cartilage on the posterior side of the trachea?
- If one is intubating a patient, may push posteriorly and pierce esophagus and vice versa.
- Angle between the parts of the main bronchi
- Carina
- What are the names of the lobar bronchi on the right side? left side?
-
Right - upper, middle, and lower secondary bronchi
Left - upper and lower secondary bronchi - Where do the tertiary (segmental) bronchi lead to?
- Bronchopulmonary segments
- What is the significance of aspiration and the carina?
- Very few cough reflex/nerve fibers are inferior to the carina. Therefore, if foreign object is not coughed up prior to its passing inferior to carina, cough reflex disappears, and specimen must be removed.
- What will cancer of the right main bronchus look like?
- Enlargement of the carina or deviation of the carina which can be seen via a bronchoscope.
- What is homologous to the middle lobe of the left lung?
- Lingula
- Anteriorly, one can see the ____ surface of the lungs.
- Lateral (costal)
- What are the names of the surfaces of lungs.
-
1) Costal/Lateral
2) Medial
3) Diaphragmatic - What is a hilum?
- A concavity/depression where structures enter or leave. (ex//root of the lung)
- What are the primary structures of the root of the lung?
- Bronchus, pulmonary artery & vein
- What are the borders of the hilum of the left lung?
- Anterior (sharp), Posterior (rounded), Inferior (sharp), Cardiac Notch
- Which surface of the lung is the same as the base?
- Diaphragmatic
- What are impressions?
- Indentions in the lung caused by adjacent structures and embalming fluid. Do not happen in vivo.
- What organ lies deep to the diaphragm on the right lung? What does it do to the right lung?
- Liver. Squeezes it, making it fatter, wider, and shorter
- What is bronchomediastinoscopy?
- Taking a scope down the neck into region of lung root. Involves retrieving lymph nodes to do a biopsy.
- What are the structures of the right and left lung from superior to inferior?
-
Right - Bronchus (most posterior), Pulm. Artery, Pulm. Vein (most anterior)
Left - Pulm. Artery (most anterior), Bronchus (most posterior), Pulm. Vein - The secondary bronchus that lies above the pulm. artery in the right lung is called ____?
- Eparterial bronchus
- What are the smallest portions of the lungs that can be resected and removed due to disease?
- Bronchopulmonary (BP) Segments
- How many lobes, BP segments, and tertiary bronchi are in the right/left lung?
-
Right - 3 lobes, 10 tertiary bronchi supplying 10 BP segments
Left - 2 lobes, 10 tertiary bronchi (fused to form 8) supplying 10 BP segments - The apex of a BP segment is towards the ____ surface of the lung. BP segments have their own arterial supply which follows the _____ in the middle of each BP segment.
- medial;tertiary bronchi
- BP Segments of Right Lung
-
Upper lobe - apical, posterior, and anterior
Middle lobe - medial and lateral
Inferior lobe - anterior basal, posterior basal, medial basal, lateral basal, and superior - BP Segments of Left Lung
-
Upper lobe - Apical/Posterior (usually fused), Anterior
Middle lobe - Superior and inferior lingular
Inferior lobe - anterior/medial basal (usually fused), posterior basal, lateral basal, and superior - Give the names of the divisions past tertiary bronchi
- tertiary bronchi -> bronchiole (without cartilage) -> alveolar sac -> alveoli
- What is the diameter of the respiratory passageway for bronchioles and the diameter of bronchioles themselves?
-
passageway - about 1 mm
bronchiole - about .5 mm - What happens in emphysema?
- Air blows out of the alveoli and lung looks transparent because you are looking in the alveoli
- About how many alveoli are there per lung?
- 300-400 million
- What do the Bronchial arteries supply? Pulmonary arteries?
- Bronchi and connective tissue of the lung; send deoxygenated blood to alveoli
- Give the origin and termination of the bronchial arteries going to the right lung. Left?
-
Right - 1 artery arises from 3rd posterior intercostal artery
Left - 2 arteries arise from aorta and follow bronchi and run on posterior aspect of bronchial tree - __A__ pass through the center of the BP segment while __B__ course intersegmentally
-
A. Pulmonary and Bronchial Arteries
B. Pulmonary Veins - Can one remove the BP segments without interfering with the pulmonary veins carrying oxygenated blood?
- Yes
- If lymph drainage is blocked in the lungs, where will it drain to?
- Axillary lymph nodes
- What are the tracheobronchial lymph nodes beginning with the smallest drainage?
- Pulmonary (intrapulmonary) -> Hilar (bronchopulmonary) -> Superior/Inferior tracheobronchial -> Paratracheal tracheobronchial -> bronchomediastinal lymph trunk -> junction of IJV and right/left sublavian
- What is another name for the Inferior tracheobronchial lymph nodes? What can happen if these nodes are enlarged due to cancer?
- Carina lymph nodes. Can deviate the carina itself.
- How can lymph go from left to right lobe?
- Travels along transversing lymph passages from left inferior lobe to the right side.
- Why can't a physician be assured that malignancy on the right lung is the only place that it has spread if he biopsies right side lymph nodes?
- It could have spread from the left side to the right side (very rare). 99% ipsilateral-same side
- What drains into the right lymphatic duct? What does it drain into? How much lymph of the body does it drain?
- Bronchomediastinal trunk drains into it. It drains into Subclavian trunk/Jugular trunk. 25%
- How much lymph of the body does the thoracic duct drain?
- 75%
- What does lung cancer show up as in a radiograph? 55% of lung cancer occurs in which lobe? Second most common site?
- Bright white spot; Upper right lobe; Upper left lobe
- What are the subdivision plexuses of the cardiac plexus?
- Pulmonary & Esophageal
- What do parasympathetic fibers of the vagus nerve do?
- Bronchoconstrict, dilate blood vessels, secretomotor (gland secretions)
- What do sympathetic fibers do to lungs?
- Bronchodilation, constrict blood vessels, inhibit gland secretions
- What does asthma do, and what type of drugs would you use to treat it?
- It constrctions bronchiotree, so patient needs a sympathomimetic drug (drug that mimics sympathetic). This will cause air passages to be dilated, constrict blood vessels, and inhibit glands.
- Cough Reflex/Pain/Pressure sensors are what type of 3 letter code nerve fiber?
- GVA
- Where is the presynaptic fiber of the vagus nerve? Where is the synapse?
- Brainstem; Synapse in pulmonary plexus and fibers proceed to bronchial tree
- Give the course of sympathetic fiber innervation of thoracic viscera. What are these branches called?
- Fiber originates in gray matter. Axon proceeds out, running in white ramus communicans to sympathetic trunk. Fibers synapse and post-ganglionic fibers run directly to heart, with subdivisions to lungs/esophagus; Splanchnic
- What is the pulmonary ligament? What is superior to it that covers lung structures at root?
- Communication between the visceral pleura and the parietal pleura; Pulmonary sleeve
- What is the recess near the cardiac notch?
- Costomediastinal recess
- What can an extra cervical rib do (1% of population)?
- Put pressure on brachial plexus and cause muscle pain in upper limb when limb elevated
- How does Herpes Zoster (chicken pox) work?
- Causes horrible pain. Lies dormant in dorsal root ganglia, and suddenly disseminates itself out to intercostal nerve (ventral primary ramus) and can go out cutaneous branches.
- Why is the visceral pleura insensitive to pain?
- Due to its autonomic innervation
- What are some after-effects of a collapsed lung due to tension pneumothorax (usually due to fractured rib)? Where should air be withdrawn in this case?
- Occlusion of veins/arteries; 2nd Intercostal space
- On an x-ray how can you tell if blood is present in pleural cavity?
- There is a straight line at the bottom when the fluid is water and not a straight line when there is blood present.
- Where is the referred pain due to pleuritis?
- Referred from parietal pleura to cutaneous distribution of intercostal nerve.
- What is hemothorax and how does it happen?
- When blood enters the pleural cavity. Caused by trauma such as stab wound or fractured rib. Also can be caused by lung disease.
- Which intercostal nerves supply the parietal viscera? Skin of anterior abominal wall?
- Upper 12 intercostal nerves; Lower 6 intercostal nerves
- Where must someone insert a needle for thoracocentesis for fluid?
- Insert along superior border of rib, Between 4th and 5th intercostal in mid-axillary line
- Layers a needle must go through in a thoracocentesis:
- Skin, superficial fascia, superficial thoracic muscles, ribs, external intercostal, internal intercostal, VAN, innermost intercostal, endothoracic fascia, parietal pleura, pleural cavity, visceral pleura, lung
- Care must be taken not to injure the _____ when performing a thoracocentesis. How can pain be managed in this procedure?
- Spleen; Perform nerve block in intercostal space at angle of the rib (what you sleep on at night). Insert needle in contact with lower border of rib, withdraw slightly, point caudal, slip under rib and enter intercostal space (dont injure VAN)