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1

2

Label the boxes from top down

Jugular notch

Clavicle

Sternal angle

Costal margin

3

Describe the anterior associations of the ribs and their costal cartilages

Ribs 1-7:

Connected by costal cartilages directly to sternum

Ribs 8-10:

Connected by costal cartilage to the costal cartilage above

Ribs 11-12:

Free floating, no connection to sternum/cartilage

4

Label this diagram from top down

The typical rib:

Head

Neck

Shaft

2 articular facets separated by crest

Tubercle (Top = articular, Bottom = non-articular)

Costal groove

5

What ribs are considered typical?

Ribs 3 to 9

6

Label each of these ribs with their number and features that make them 'atypical'

Top to bottom:

Rib 1:

shortest, broadest, most curved, only has 1 facet on head

Rib 2:

Poorly marked costal groove

Ribs 11 + 12:

Floating

Single facet on head

No tubercle

Tapering anterior end

7

Label the boxes

First set of boxes

Participants in joint of head of rib:

Body of vertebra superior to rib

Intervertebral disk

Body of vertebrae same number as rib

 

Second set of boxes

Costo-transverse joint:

Transverse process of vertebra of same number as rib

Tubercle of rib

Axis of rib rotation

Movements (the arrows):

Elevation

Depression

 

8

Label the black and red boxes

Black, top left clockwise:

Axis of movement

Axis of movement

Increase in sagittal diameter

Increase in transverse diameter

Neck of rib

Red, left to right:

Lower rib

Upper rib

9

What are the three layers of intercostal muscle

Give a brief description of each

External intercostals:

Fibre direction is posterior to anterior from the inferior border of the superior rib to the superior border of the inferior rib

Outermost

Internal intercostals:

Fibre direction is anterior to posterior from the inferior border of the superior rib to the superior border of the inferior rib

Middle layer

Innermost intercostals:

Run from the inferior border of the superior rib to the superior border of the inferior rib

Innermost layer

10

Label the boxes top to bottom

External intercostal muscles

Internal intercostal muscles

Innermost intercostal muscles

11

Describe the actions of the external intercostal muscles

Elevation of the upper ribs in a 'pump handle' movement to increase A-P diameter of thorax

Elevation of lower ribs in a 'bucket handle' movement increasing the lateral diameter of the thorax

12

Describe the actions of the internal and innermost intercostal muscles

Depress the ribs during forced expiration

Reduces A-P and lateral diameter

13

What muscles are responsible for passive expiration?

No muscles, passive process driven by elastic recoil of lungs and chest wall

14

What structures are labelled here?

Two neurovascular bundles

Main bundle includes intercostal vein, artery and nerve and runs in costal groove of superior rib

Collateral bundle runs along the superior border of the inferior rib

15

Describe the 12 intercostal nerves

Course:

Appear from the anterior rami of thoracic spinal nerves (T1 - T12)

Run between internal and innermost intercostal muscles

Supply:

Intercostal muscles in corresponding space

Parietal pleura

Overlying skin

16

Label the boxes from top left clockwise

Paravertebral chain

Intercostal nerve

Posterior intercostal artery

Anterior intercostal artery

 

17

What is supplied by the intercostal arteries?

Intercostal muscles

Parietal pleura

Overlying skin

18

Label boxes in two rows, Left row then right row, top to bottom

Left:

Superior vena cavae

Azygous vein

Hemiazygous

IVC

Right:

Anterior intercostal vein

Internal thoracic vein

Posterior intercostal veins

19

From where do the posterior and anterior intercostal arteries arise?

Anterior:

Internal thoracic artery (branch of the subclavian)

Posterior:

Thoracic aorta

Superior intercostal artery (From the costo-cervical traunk, a branch of the subclavian)

20

Describe the venous drainage of the chest wall

Primarily into the Azygous system ---> SVC

Some drainage into internal thoracic vein

21

Describe the structure of the diaphragm

Central tendon + Peripheral  uscle

Peripheral muscle areas:

Sternal - Arising from xiphisternum

Costal - Arising from inner aspects of the 7-12 costal cartilages

Vertebral - Arising from arcuate ligaments (thickenings of fascia over the posterior abdominal wall muscles) + crura

22

Label black boxes from top left clockwise

IVC opening

Central tendon

Oesophaseal opening

Aortic hiatus w/median ligament overlying

Left crus

Right crus

Lateral arcuate ligament

Medial arcuate ligament

23

Give the vertebral level of the openings in the diaphragm and attachment sites of the right and left crus

Oesophagus: 

T10

Vena cava:

T8

Aortic Hiatus:

T12

Right crus:

L4

Left crus:

L3

24

What is the function of the diaphragm in relation to breathing?

Main muscle of inspiration

Contraction causes descent of diaphragm, expanding the thoracic cavity

25

Describe the nerve supply of the diaphragm

Include any additional innervation of that nerve

Phrenic nerve

Roots:

C3 - 5 (3-4-5 keep you alive)

Motor innervation:

Diaphragm

Sensory innervation:

Pericardium

Mediastinal and diaphragmatic portions of parietal pleura

Both surfaces of diaphragm

26

What muscles/actions are involved in inspiration?

What are the results of these muscle actions?

External intercostals:

Elevation of ribs

Contraction of diaphragm:

Descent

Sternocleidomastoids:

Elevates sternum

Scalenes:

Elevate and fix upper ribs

Results:

Increased transverse and A-P diameter

Increase in vertical dimension

27

Describe the process of expiration in regards to actions/muscles involed

Quiet expiration:

No muscles, just elastic recoil

Forced expiration:

Internal and innermost intercostals

Rectus abdominus

External and internal obliques

Transversus abdominus

Results of either passive or forced:

Decrease in AP and transverse diameter

Decrease in the vertical dimension

28

What is the involvement of the pleura in respiration?

Briefly describe how this works

As muscle action expands the thorax and the parietal pleura the pleural seal ensures that the visceral pleura and hence the lung also expand

The pleural seal is formed from surface tension between fluid molecules of the serous secretions in the pleural cavity

29

What is the clinical relevance of the pleural seal?

Puncture of the parietal pleur breaks the pleural seal, allowing the visceral and parietal pleura to separate, this is a pneumothorax (lung collapse)

30

Decribe the nerve supply of the pleura

Parietal:

Somatic innervation (including pain) and autonomic

Visceral:

Only autonomic

31

Describe the blood supply of the pleura

Parietal:

Intercostal arteries and internal thoracic artery

Corresponding veins drain

Visceral:

Bronchial arteries

Bronchial veins

32

Describe the anatomical location and important features of the trachea

Extends from the lower border of the cricoid cartilage to the division od bronchi at the carina (Spinal level T4/5)

Fibro-cartilagenous tube

18-22 U shaped cartilage rings

Trachealis muscle posteriorly

33

What is the clinical relevance of the angle of tracheal bifurcation?

If angle is wider than normal this indicates swollen tracheo-bronchial lymph nodes

34

What is a broncho-pulmonary segment and what is the clinical relevance?

Broncho-pulmonary segment:

Area of lung supplied by its own segmental bronchus and segmental branches of pulmonary arteries and veins

Pyrimidal in shape, apex towards hilum, base towards lung surface

Clinical:

Segment can be isolated and removed with little damage to others (E.g. removal of small primary or metastatic tumours)

35

What is the apex of the lung and why is it clinically relevant?

Apex:

Superior portion of the lung extending superiorly through the superior thoracic inlet and to the base of the neck

Clinical:

Apical lung tumours can compress structures in root of neck (E.g. brachial plexus, subclavian vessels, sympathetic trunk)

Subclavian vein cannulation can lead to pleural puncture (pneumothorax)

36

What structures pass throught the lung Hilum?

Pulmonary and bronchial arteries and veins

Bronchi

37

From where do the bronchial arteries arise? where do they supply?

What is the role of the bronchial arteries in venous drainage of the lungs?

Arteries:

Arise from aorta on left and 3rd intercostal on right

Supply bronchial tree from the carina to the respiratory bronchioles, visceral pleura and connective tissue

Veins:

Most drainage is via pulmonary veins rather than bronchial

Superifical bronchial veins drain the visceral pleura and bronchi in the hilar region into the azygous vein on the right and hemiazygous vein on the left

Deep group drain the deeper bronchi into the pulmonary vein

38

Label the black boxes and identify each lung

Lung pictured left, boxes from top to bottom, left to right:

Right lung

Pulmonary arteries

Bronchus

Pulmonary veins

Pulmonary ligament

Lung pictured right, boxes from top to bottom:

Left lung

Pulmonary artery

Bronchus

Pulmonary veins

 

39

PIctured are the right and left mediastinal spaces with lungs removed, identify the structures labelled

Left picture, top to bottom:

Sympathetic chain

Vagus nerve

Phrenic nerve

Right picture, top to bottom:

Reccurent larangeal nerve (branch of vagus)

Vagus nerve

Phrenic nerve

Aorta

40

Label the boxes and identify the borders of each mediastinal space

Boxes, top to bottom, left to right:

Anterior

Body of sternum

Fibrous pericardium

Superior

Thoracic inlet

Plane passing throught sternal angle and lower border of T4

Middle

Between anterior and posterior

Posterior

Fibrous percardium

Vertebral bodies

 

41

Describe the nerve supply of the lungs

Lung recieves innervation from differnt nerves all via the pulmonary plexuses at each lung hilum

Vagus Efferent:

Parasympathetic nerves provide motor innervation to bronchial smooth muscle (constriction)

Pulmonary vasoldilation

Secretomotor innervation to mucous glands

Vagus afferent:

cough reflex

Subserving pain

Sympathetic trunk:

Bronchodilation

Vasoconstriction

42

Describe the lymphatic drainage of the lungs

Superficial sub-pleural lymphatic plexus:

Lies deep to visceral pleura

Drains lung parenchyma and visceral pleura

Drain into hilar lymph nodes at each lung hilum

Deep broncho-pulmonary lymphatic plexus:

Lies in the submucosa of bronchi and peribronchial tissue

Drain into the hilar nodes

43

What si the normal composition of alveolar air? Give partial pressures

pO2 = 13.3kPa

pCO2 = 5.3kPa

44

Give the normal gaseous content of mixed venous blood returning to the lungs

pO2 = 6kPa

pCO2 = 6.5kPa

Can vary with metabolism

45

Identify the direction of gas gradients across the alveolar membrane and hence give direction of movement of each gas

pO2:

13.3kPa > 6.0kPa

Therefore O2 moves into alveolar capillaries

pCO2:

5.3kPa < 6.5kPa

Therefore CO2 diffuses into alveoli

46

Aside from gradient what factors influence diffusion of gases across the alveolar membrane?

Surface area (Ideally large)

Diffusion resistance (Ideally low)

47

What factors influence diffusion resistance?

Nature of gas

Nature of barrier

48

Describe the diffusion barrier in the lungs

Diffusion occurs across alveolar wall and into RBCs therefore barrier made up of:

Epithelium of alveolus

Tissue fluid 

Endothelial cells of capillary

Plasma

Red cell membrane

Total = 0.6um

49

Which diffuses faster, Co2 or O2? Why?

CO2 (x21):

Gases diffuse at rate proportional to solubility

Therefore CO2 faster

 

50

Apart from solubility what other feature of gases goes towards determining diffusion rate?

Molecular weight:

Gases diffuse at rate inversely proportional to molecular weight

51

Houw long does it take for partial pressures of alveolar gases and blood gases to equilibrate in the lung?

How long do blood cells spend in the alveolar capillaries and why is this relevant?

0.5s

1s

Relevance:

Plenty of leeway, diffusion not limiting on lung function

52

What are the partial pressures of gases in blood leaving the alveolar capillaries?

pO2 = 13.3kPa

pCO2 = 5.3kPa

53

Describe the process of ventilation and what it achieves

Expansion of the lungs increasing the volume of respiratory bronchioles and alveolar ducts, drawing air into them

Air is not drawn directly into alveoli, fresh air is an incorrect mix

Raises pO2 and lowers pCO2 in alveoli

54

Label the boxes and define the terms

Top to bottom

Inspiratory reserve:

Extra volume that can be breathed in over that inspired at rest

Tidal volume:

Volume in and out with each breath at rest

Expiratory reserve volume:

Extra volume that can be breathed out over that expired at rest

55

Label the box and define

Give how this volume is measured

Residual volume:

Volume left in lungs at maximal expiration

Measured with a helium dilution test

 

56

Label the box, define it and give it's typical value

Vital capacity:

Measured from maximal inspiration to maximal expiration

About 5L in typical adult

Cn be altered by disease

57

Label the box, define it and give it's typical value

Inspiratory capacity:

Measured from resting expiratory level to maximal inspiration

Typically 3L

58

Label the box, define it and give typical value

Functional residual capacity:

Volume of air in lungs at resting expiratory level

(Expiratory reserve + Residual volume)

Typically 2L

59

Define ventilation rate

Volume of air moved into and out of a space (lungs) per minute

Product of volume per breath and resp rate

60

Give the exquation of pulmonary ventilation rate and the typical values

Tidal volume x resp rate

Typically 8L.min-1

Can exceed 80L.min-1 in exercise

61

How does alveolar ventilation rate differ from pulmonary ventilation rate?

Discounts volume of air only moved into dead spaces in the lung where no gas exchange occurs (bronchi etc)

62

Define 'serial dead space'

How is it measured?

Give a typical value

 

Volume of the airways

Used to be known as 'anatomical dead space'

Measured via nitrogen washout test

Typically 0.15L

63

Define 'distributive dead space' and 'physiological dead space'

Give typical values

Distributive:

Parts of the lungs that do not support gas exchange but are not airways, including:

- Dead or damaged alveoli

- Alveoli with poor P/V ration

Physiological:

Distributive + Serial dead space to give total 'dead space'

Typically 0.17L

64