Anatomy

Question 1

What does the upper respiratory tract include?

Answer 1

• The right and left nasal cavities
• The oral cavity
• The naso- oro- and laryngo- pharynx
• The larynx

Question 2

What does the lower respiratory tract include?

Answer 2

• Trachea
• Right and left main bronchi
• Lobar bronchi (located within the lungs)
• Segmental bronchi (located within the lungs)
• Bronchioles (located within the lungs)
• Alveoli (located within the lungs)

Question 3

Where is the transition point where the larynx becomes the trachea?

Answer 3

The C6 vertebra

Question 4

Describe the pleural cavity

Answer 4

• Pleural cavity is the space surrounding each lung.
• In adult lung visceral (in contact with lungs) pleura and parietal (in contact with body wall) pleura.
• The space between is filled with pleural fluid, this causes the two layers to stick together.

Question 5

What are the lobes of the left and right lung?

Answer 5

• The Right lung has three lobes: Superior, inferior and middle.
• The Left lung has two lobes: Superior and inferior. The absent middle lobe is thought to be due to the presence of the heart.

Question 6

What are bronchopulmonary segments?

Answer 6

the area of lung lobe that each one of the segmental bronchi supply with air, each lung has 10 bronchopulmonary segments
• Each segment own blood supply, venous drainage, lymphatic drainage etc. All segments can be isolated surgically if required.

Question 7

What are the major muscles involved in inspiration that contract every inspiration and relaxation causes passive expiration?

Answer 7

External intercostal muscles and the diaphragm

Question 8

What is contained within intercostal spaces?

Answer 8

Each intercostal space carries a neuro-vascular bundle containing a nerve, artery and a vein. (going vein, artery nerve from superior to inferior). The neuromuscular bundle is between the internal intercostals and the innermost intercostals and lie in the subcostal groove under the rib.

Question 9

Describe the origins of nerves, arteries and veins from the intercostal spaces

Answer 9

• Intercostal nerve of the intercostal space is coming from single origin anterior ramus of spinal nerve.
• Arteries and vein have dual anterior and posterior origins.

Question 10

Describe the nerve supply of the diaphragm

Answer 10

• Diaphragm nerve supply is the phrenic nerve
• Phrenic nerve is produced by multiple spinal nerve anterior rami.
• The muscular part of the diaphragm is supplied by the C3,4 and 5 anterior rami (phrenic nerve)

Question 11

Describe inspiration mechanics

Answer 11

1. Diaphragm contracts and descends which increases vertical chest dimension
2. Intercostal muscles contract elevating ribs which increases anterior to posterior and lateral chest dimensions
3. The chest walls pull the lungs outwards with them (pleura) and air flows into the lungs

Question 12

Describe expiration mechanics

Answer 12

1. Diaphragm relaxes and rises which decreases vertical thoracic dimension
2. Intercostal muscles relax lowering ribs which decreases anterior to posterior and lateral chest dimensions
3. Elastic tissue of lungs recoils and air flows out of lungs

Question 13

What are the muscles of active expiration?

Answer 13

Abdominal muscles

Question 14

What are the accessory muscles of inspiration that contract only during forceful inspiration?

Answer 14

Internal intercostals, pectoralis minor and major, scalenus muscles and the sternocleidomastoid

Question 15

What surface anatomy is used to auscultate the lung apex?

Answer 15

Auscultate superior to the medial third of the clavicle

Question 16

What rib does the horizontal fissure follow?

Answer 16

Rib 4

Question 17

Where does the obique fissure follow?

Answer 17

Rib 6 anteriorly rising to T3 posteriorly

Question 18

Where should you auscultate the middle lobe?

Answer 18

Between ribs 4 and 6 in the mid clavicular and mid auxiliary lines ON THE RIGHT HAND SIDE

Question 19

What is the carina and what level is it at.

Answer 19

Ridge of cartilage in the trachea that occurs between division of two main bronchi. Level of rib 2

Question 20

What is the site used in depressing a tension pneumothorax?

Answer 20

The 2nd intercostal space

Question 21

Where do bronchial arteries arise from?

Answer 21

The thoracic aorta usually.

Question 22

Where is the visceral pleura continuous with the parietal pleura?

Answer 22

At the hilum of the lung

Question 23

Describe the tracheobronchial tree?

Answer 23

Trachea bifurcates at the level of the sternal angle into main bronchi one to each lung. Each main bronchus divides into secondary lobar bronchi which each supply a lobe of the lung. Each lobar bronchi divides into segmental bronchi that supply the bronchopulmonary segments. These segmental bronchi divide into conducting bronchioles, then terminal bronchioles then respiratory bronchioles that end in alveoli. Bronchioles lack cartilage in their walls.

Question 24

What two cranial nerves are stimulated in coughing?

Answer 24

Cranial nerves 9 (glossopharyngeal) and 10 (vagus)

Question 25

* Carotid sheath are protective tubes of ____1____ deep fascia * It contains the _____2___ nerve * Vagus nerve travels ____3____ carotid sheath but ______4____ nerve on surface.

Answer 25

cervical vagus within glossopharyngeal

Question 26

Where are the nerves from the lung and visceral pleura derived from?

Answer 26

Pulmonary plexuses

Question 27

The ___1____ is narrowest part of the airway and the intrinsic muscles of the larynx ____2____ the vocal cords during the cough reflex

Answer 27

Rima glottidis | Adduct

Question 28

Phrenic nerve is ______ and made by coming together of __________ Phrenic nerve passes _____ to the root of the lung

Answer 28

Bilateral C3,4 and 5 Anterior

Question 29

One function of vagus nerves important to coughing is to supply ________ and ______ axons to the larynx. Vagus nerve is ______ to the root of the lung.

Answer 29

somatic sensory somatic motor posterior

Question 30

What is the linea alba?

Answer 30

Midline where aponeurosis of right and left blend together

Question 31

Consequence of chronic cough?

Answer 31

Pneumothorax | Hernia

Question 32

What is the difference between a small and large pneumothorax?

Answer 32

Small has < 2cm gap between lung and parietal pleura | A large pneumothorax results in > 2cm gap between lung and parietal pleura.

Question 33

What happens in a tension pneumothorax?

Answer 33

* The torn pleura can create a one-way valve that permits air to enter the pleural cavity on each inspiration but prevents air escaping again on expiration * With each inspiration more air enters the pleural cavity * The pneumothorax expands and the lung collapses towards its root * Eventually the build-up of air in the pleural cavity applies tension (pressure) to the mediastinal structures

Question 34

The trachea will deviate away or towards the pneumothorax and where is this palpable?

Answer 34

Away from the pneumothorax and this is palpable at the jugular notch.

Question 35

Describe the safe triangle and management of a large pneumothorax.

Answer 35

1. Needle aspiration (thoracentesis) 2. The siting of a chest drain Both these procedures are done by 4th or 5th intercostal space in the midaxillary line The “safe triangle”: - The anterior border of latissimus dorsi - The posterior border pectoralis major - Axial line superior to the nipple - Need to be in middle of intercostal space to avoid arteries, nerves and veins.

Question 36

Describe emergency management of a tension pneumothorax

Answer 36

Large gauge cannula inserted into pleural cavity via the 2nd or 3rd intercostal space in the midclavicular line of the side of the tension pneumothorax using sternal angle (level of rib 2) as a guide.

Question 37

What are hernia? And two causes?

Answer 37

Hernia are any structure passing through another, ending up in the wrong place. • Hernia can form where there may be weakness of one structure • Another cause is repeated bouts of increased intra-abdominal pressure on the diaphragm and the anterolateral abdominal wall (including the inguinal region/femoral triangle) as then structures are pushed through the wall to produce a hernia.

Question 38

What direction does the external oblique run in ?

Answer 38

Superolateral to inferomedial direction

Question 39

What direction does the internal oblique run in?

Answer 39

Superomedial to inferolateral

Question 40

What direction does the transversus abdominus run in?

Answer 40

across

Question 41

What are all the anterolateral abdominal muscles innervated by?

Answer 41

Thoracoabdominal nerves

Question 42

External intercostals ______ extend anteriorly as far as the sternum but internal intercostals ___ extend anteriorly all the way to the sternum

Answer 42

do not | do

Question 43

Findings on examination of pneumothorax?

Answer 43

* reduced ipsilateral chest expansion * reduced ipsilateral breath sounds * hyper-resonance on percussion

Question 44

Describe the two types of diaphragmatic hernia?

Answer 44

Paraoesophageal hiatus hernia The herniated part of the stomach passes through the oesophageal hiatus to become parallel to the oesophagus and in the chest Sliding hiatus hernia The herniated part of the stomach slides through the oesophageal hiatus into the chest with the gastro-oesophageal junction

Question 45

What is the weakness in the inguinal area caused by and what are the two types of hernia you can get?

Answer 45

Weakness due to the inguinal canal Direct inguinal hernia A “finger” of peritoneum is forced through the posterior wall of the inguinal canal and directly out of the superficial ring into the scrotum Indirect inguinal hernia A “finger” of peritoneum is first forced through the deep ring into the inguinal canal and then out of the superficial ring into the scrotum

Question 46

How do you differentiate between the two types of inguinal hernia?

Answer 46

1. ‘reduce’ the hernia 2. occlude the deep ring with fingertip pressure 3. ask the patient to cough if it is a direct hernia, the lump will reappear if it is an indirect hernia, the lump will not reappear

Question 47

5 types of hernia associated with chronic cough?

Answer 47

1) Diaphragmatic herniae (e.g. paraoesophageal & sliding hiatus herniae) 2) Umbilical herniae (congenital & acquired) 3) Incisional herniae (any surgical incision of the abdominal wall is vulnerable) 4) Inguinal herniae (direct & indirect - see later in this session) 5) Femoral herniae (in the femoral triangle of the proximal anterior thigh - more in Year 2)

Question 48

Describe the route of the inguinal canal starting at the deep ring in males

Answer 48

``` transversalis fascia transversus abdominus internal oblique external oblique aponeurosis deep fascia superficial fascia scrotal skin ```

Question 49

What are the boundaries of the inguinal canal?

Answer 49

Floor = inguinal ligament Anterior wall = external oblique aponeurosis Posterior wall = transversalis fascia (lateral) and conjoint tendon (medial) Roof = transversus abdominis and internal oblique

Question 50

What are the contents of the inguinal canal?

Answer 50

Spermatic cord in males or round ligament of the uterus in females. Also contains blood and lymphatic vessels as well as the ilio-inguinal nerve and the genital branch of the genitofemoral nerve.

Question 51

The aponeuroses of internal oblique and transversus abdominis join to form the conjoint tendon ______

Answer 51

Medial to the deep inguinal ring.

Question 52

What nerve provides motor innervation to the soft palate and intrinsic laryngeal muscles

Answer 52

Vagus nerve

Question 53

Lymphatic drainage of the lungs?

Answer 53

Tissue- bronchopulmonary- tracheobronchial (superior and inferior) and then into the bronchomediastinal trunk which drains into the venous angles

Question 54

Which bronchus has a higher rate of inhalation of foreign material?

Answer 54

The right