1
Q
What are the three spaces in the chest?
A
Two pulmonary cavities and mediastinum
2
Q
Describe the superior and inferior thoracic apertures
A
- Superior thoracic aperture
- Open to the neck
- Apex of the lung protrudes above it
- Neck wound could damage the lung
- Inferior thoracic aperture
- Closed by the diaphragm
3
Q
What is inside the pleural space?
A
Nothing
- Lungs are “intrapleural”
- Invested into pleural sacs, but not inside the space
- Small amount of fluid inside, but it is a potential space and basically empty
4
Q
What is the embryonic origin of the lungs?
A
Endoderm
- Out-branching of endodermal gut during development
5
Q
How are the pleural cavities formed?
A
Bud of lung grows into empty pleural space
- Lung covered by visceral pleura
- Sac covered with parietal pleura
- Diaphragmatic pleura
- Mediastinal pleura
- Costal pleura
- Cervical pleura
6
Q
What vertebrae do the phrenic nerves come from?
A
C3, 4, 5
- These neurons keep a person alive
- Spinal cord injury at C3 is deadly
- Person would need to be on a respirator
7
Q
What kind of nerve is the phrenic?
A
Typical spinal nerves
- Diaphragm is a skeletal muscle
- You can control breathing when you want to
8
Q
What are the components of the phrenic nerve?
A
- Somatomotor
- General sensory
- Postganglionic sympathetic (to blood vessels in diaphragm)
9
Q
What is the name for the space in the pleural sac that is not occupied by the lung during passive respiration?
A
Costodiaphragmatic recesses
10
Q
What are the positions of the lung and the parietal pleura at the midclavicular line?
A
- Lung: extends to 6th rib
- Parietal pleura: extends to 8th rib
11
Q
What are the positions of the lung and parietal pleura at the midaxillary line?
A
- Lung extends to 8th rib
- Parietal pleura extends to 10th rib
12
Q
What are the positions of the lung and parietal pleura at the paravertebral line?
A
- Lung: extends to 10th rib
- Parietal pleura: extends to 12th rib
13
Q
What are the surface landmarks for the right lung?
A
- Horizontal fissure: 4th rib
- Oblique fissue: 6th rib
14
Q
What is the surface landmark for the oblique fissure of the left lung?
A
6th rib
15
Q
What are the surface landmarks for the lung and the parietal pleura at the parasternal line?
A
- Lungs: rib 4
- Parietal pleura: rib 6
16
Q
What are pleural recesses?
A
Potential spaces which can fill with blood, air, and water in pathological states
- Can be blunted or increased, depending on the pathology
17
Q
How can pleural recesses be altered pathologically?
A
- They can be blunted
- Fluid, pressure
- They can have an increased angle
- Elevated pressure in the abdominal cavity (e.g. GI obstruction)
18
Q
Branching from the trachea, what enters the hilum of the lung on each side?
A
- L side: primary bronchus
- R: secondary bronchi
- Upper and lower lobes
19
Q
Where are the phrenic and vagus nerves situated in relation to the hilum?
A
- Phrenic nerve runs anterior to hilum
- Vagus nerve runs posterior to hilum
20
Q
Describe the organization of the root of the lung on the right
A
- Pulmonary arteries (blue) are anterior to the bronchus
- Pulmonary veins (red) are always anterior and inferior to all other structures in the root
21
Q
Describe the organization of the root of the lung on the left
A
- Pulmonary arteries (blue) lie superior to the bronchi
- Pulmonary veins (red) are inferior and anterior to all other structures
(RALS - R is Anterior, L is Superior)
22
Q
What are bronchopulmonary segments?
A
The units of lung supplied by one tertiary (segmental) bronchus and its accompanying artery
- These structures are intrasegmental
- They follow each other
- The pulmonary vein that drains a segment is intersegmental
- Veins are on the border
- 1 vein goes to 2-3 segments
- 10 on the Right, 8-10 on the Left
23
Q
Is it possible to remove just one bronchopulmonary segment of a lung?
A
Yes
- The fact that they each have their own blood supply and airway makes it possible to remove a diseased segment
- The fact that veins drain adjacent segments makes it necessary to tie off the tributaries to the vein
- Much more common to remove an entire lobe thanjust a segment
24
Q
What is the point at which the trachea branches?
A
Carina
25
Where do aspirated objects tend to lodge?
Right main or inferior lobar bronchus
* R primary is more vertical and wider
* On the R, the mainstem bronchus divides before entering the lung
* The middle lobar is a branch of the inferior
26
Where does the trachea split?
At the junction between middle and superior mediastinum: **angle of Louis**!
* Junction of the ascending aorta and the arch
* Trachea does not extend into inferior mediastina
27
Does the pleura feel pain?
* The visceral pleura does not
* Mediastinal, costal, and diaphragmatic parietal pleura do
Pain sensations are allcarried by different nerves
28
Where does costal pleural pain come from?
Intercostal nerves
29
Where does the diaphragmatic pleural pain come from?
Phrenic nerve
* Mediastinal pleural pain is from phrenic nerve as well
30
Where does the nerve supply to the lung come from?
Same as that of that to the heart because the source is the same, they just continue onto the pulmonary plexus
* **Cardiopulonary plexus**
* Branches from vagus
* Branches from sympathetic chang - coming from chain ganglia via cardiac nerves
* Tiny branches form thorax to plexus
* Visceral afferents and visceral motor fibers
31
What are the two blood supplies to the lung?
* Pulmonary circulation
* Most lung tissues
* Oxygen from passive diffusion
* Bronchiole arteries
* Structures comprising the root and supporting tissues
* Generally tow on the left and one on the right - superior and inferior
32
What are the potential branches of the aorta?
* Esophageal
* Intercostal arteries
* Subcostal arteries
* Superior phrenic artery
* Coronary
* Subclavian
* Carotid
* Brachiocephalic
33
What does the brachiocephalic artery branch into?
Becomes **R common carotid** and **R subclavian**
34
What does the subpleural plexus drain?
The parenchyma
Then drains to the bronchopulmonary nodes
35
Which lymph nodes are associated with the root structures?
Pulmonary nodes
All of the channels are freely connected
36
What structures are contained within the superior mediastina?
* Aortic arch
* Roots of great vessels
* Esophagus
* Trachea
* Pulmonary arteries and extra pericardial part of the trunk
* Vagal, phrenic, left recurrent laryngeal, cardiac nerves
37
What structures are found in the inferior anterior mediastina?
* Fat
* Branches of the internal thoracic artery
* Some thymus in children
38
What is the pathological significance of the inferior anterior mediastina?
Enlargement of the lung tissue leads to enlarged retrosternal space
39
What structures are found in the inferior middle mediastina?
* Everything in the paricardial sac - heart, ascending aorta, pulmonary trunk, and some SVC
* Also, phrenic nerves - they lie on top of the sac
40
What structures are found in the inferior posterior mediastina?
* Vessels, nerves, and visceral structures anterior to the vertebrae, posterior to the heart, and between the parietal pleura
* Descending aorta
* Esophagus and esophageal plexus
* Thoracic duct and associated lymph nodes
* Greater, lesser, and least throacic splanchnic nerves
* Azygos and hemi azygos system of veins
* Sympathetic chain (tehcnically alongside vertebrae)
41
What are the three superior branches of the aortic arch?
* Brachiocephalic
* Carotid
* Subclavian
All found in superior mediastinum
42
Which veins branch from the superior vena cava?
Brachiocephalic vein and Right subclavian vein
43
Where do the phrenic and vagus nerves lie in relation to the root of the lung?
* Phrenic lies anterior to the root of the lung
* Sensory fibers and sympathetics to the diaphragm
* Vagus runs posterior to the root of the lung
44
What are the layers that can be seen in in a scan?
From A to P
* Glandular
* Venous
* Arterial
* Respiratory
* Digestive
45
Which nerves form up the esophageal plexus?
Left and Right vagal nerves
* Break into multiple fibers to make up esophageal plexus
* Both contribute to anterior *and* posterior surface
* Fibers reconvene as vagal trunks after the plexus
46
What are the parameters of the posterior mediastinum?
* Posterior to the heart and diaphragm, anterior to the vertebral column
* BetweenT5 and T12
* Pulmonary cavities/parietal pleura on either side
47
What does the azygos system of veins drain?
Mainly intercostal spaces, also esophageal wall
* Has connection to abdominal cavity - critical for potential collateral circulation or drainage
* Valve-less system
48
Where is the thoracic duct located?
Posterior mediastina
* Between esophagus and aorta
* Thin-walled, translucent structure
49
Where do sympathetic nerves to the abdominal cavity synapse?
* Come off the chain as preganglionic nerves
* Synapse in the **preaortic** or **prevertebral plexus **
50
Where do simple thoracic splanchnics synapse?
* Come off the sympathetic chain in the posterior mediastinum as postganglionic nerves
* Go into cardiopulmonary plexus
51
What makes up the greater splanchnic nerve?
* Splanchnics come off of T5-9 and join together to form a single nerve
* Preganglionic fibers
* Synpase past the diaphragm
52
Where along the sympathetic chain can 2 communicating rami be found?
T1 - L2
53
Of the two vagal nerves, which contributes mostly to the *anterior* esophageal plesus?
Left
## Footnote
After the plexus the fibers reconvene on their way to the stomach as the anterior and posterior vagal trunks
The esophageal plexus also receives sympathetics from thoracic splanchnics
54
Which of the two vagal nerves contributes mostly to the posterior esophageal fibers?
Right
## Footnote
Mixing of fibers from right and left
After the plexus, the fibers reconvene on their way to the stomach as the anterior and posterior vagal trunks
55
What are the important branches of the thoracic aorta?
* Esophageal arteries
* Bronchial arteries
* Posterior intercostal arteries
* Superior phrenic artereis
* 2 Subcostal arteries
56
What does the celiac trunk (abdominal aorta) supply?
Gives branches to the esophagus inferiorly
57
Where does the azygos system of veins drain to?
Superior vena cava
## Footnote
Arching over the root of the lung on the right
58
Where are the azygos and hemiazygos systems?
* Azygos vein on the right side
* Left side has hemiazygos and accessory hemiazygos
59
What structures does the azygos system drain?
* Body wall
* Esophagus
* Bronchial veins
60
How does the azygos system connect to the portal system?
Indirectly, through the **esophageal venous plexus**
* Can take blood that is supposed to go to the liver
* If one system is blocked, it can go the other way
61
How do the azygos and hemiazygos veins communicate with the abdominal cavity?
Via direct connection to the ascending lumbar veins
62
Does the azygos system associate with the renal veins?
Yes - has connection from Left renal vein up to the system
63
What is the clinical significance of the esophageal venous plexus?
Dilated vessels from portal hypertension can be ruptured easily and bleed extensively
64
Where is the arch of the azygos system?
Posterior mediastinum (right)
## Footnote
Azygos vein will arch over main stem bronchus and drain into superior vena cava
65
Where is the pulmonary artery on the left side?
Superior to the mainstem bronchus
66
Where does the accessory hemiazygos system drain to?
Sends flow to the Left brachiocephalic vein → drains back to SVC
* Hemiazygos branches posterior to the esophagus and joins azygos vein
* Not everyone has a hemiazygos/accessory hemiazygos
* Only having an azygos: would see intercostals going over vertebral body and going over to right side
67
From where does the thoracic duct receive lymph?
Entire body *except* the upper right quadrant of the chest and the right side of the head
68
Where does the thoracic duct lie?
Between esophagus and thoracic aorta
* Passes from its origin just inferior to the diaphragm
* EMpties into the venous system at the junction of the left internal jugular and left subclavian vein
69
How is flow of the thoracic duct facilitated?
Changes in pressure created through respiration
70
From where does the thoracic duct collect vessels?
* Thoracic wall
* Lungs
* Heart
* Esophagus
Contains all of the lymph from lower cavity: 150-200 mL a day
Anatomy
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