The Tracheobronchial Tree and Larynx

Question 1

What is immediately posterior to the suprasternal notch?

Answer 1

Trachea

Question 2

What is the sternal angle?

Answer 2

Where trachea ends and becomes right and left bronchus

Question 3

What is the manubrium?

Answer 3

Massive, thickest and squarest of 3 main parts of sternum

Question 4

What is the angle of louis?

Answer 4

Name given for sternal angle which is a palpable feature formed from manubriosternal junction

Question 5

What are the symptoms of Tension Pneumothorax?

Answer 5

Chest pain + tightness
Cough
Blue or ashen skin (cyanosis)
Rapid heart rate
Fatigue
Anxiety
Shortness of breath
Shallow breathing
Seen respiratory distress
Asymmetrical chest expansion
Tracheal deviation on neck palpation

Question 6

What causes tension pneumothorax?

Answer 6

Secondary to mechanical ventilation
Ongoing air leak
Can occur after penetrating or blunt chest trauma or potentially after failed subclavian or jugular venous catheter insertion attempts

Question 7

Mechanism behind tension pneumothorax?

Answer 7

1) Opening in the pleura acts as 1 way valve so air in on inspiration but valve closes on expiration so can’t escape
2) Positive intrapleural pressure collapses lung
3) Eventually causes mediastinal shift to opposite side (tracheal shift)
4) This happening can cause kinking of vena cava resulting in decreased or no venous return to heart
5) Compresses the opposite lung

6) If no venous return can lead to no cardiac output = Risk of cardiac arrest

Question 8

Management of Tension Pneumothorax (non-emergency)

Answer 8

Incision made in the 5th and 6th intercostal space in midaxillary line (approx nipple line)
Tube directed superiorly toward cervical pleura for removal of air or inferiorly toward costodiaphragmatic recess for fluid drainage

Question 9

Management of Tension pneumothorax (emergency)

Answer 9

Cannula 2nd intercostal space in mid-clavicular line then chest drain

Question 10

Trachea extends from which spinal levels?

Answer 10

From larynx at level of C6 to T5 (sternal angle)

Question 11

What is the carina?

Where is it?

Answer 11

Ring of cartilage that has a hook underneath it that splits it into right and left bronchus

At level of sternal angle

Question 12

What are the layers of the trachea?

Answer 12

Mucosa includes cilia, pseudo-stratified columnar epithelium, lamina propria
Submucosa
C-shaped ring of hyaline cartilage
Adventitia

Question 13

What is the hilum?

Answer 13

Where the bronchi and pulmonary vessels enter the lung

Question 14

Difference between left and right bronchi?

Answer 14

Right is wider, shorter and more vertical

Question 15

What are the lobes in the lungs? How are they separated?

Answer 15

Left lung: Upper and lower love separated by oblique fissure
Right lung: Upper lobe, lower lobe and middle lobe
Upper and middle separated by horizontal fissure and all 3 separated by oblique fissure

Question 16

Order of the bronchial tree?

Answer 16

Main bronchi (primary)
Lobar bronchi (secondary)
Segmental bronchi (tertiary)
Terminal bronchioles
Respiratory bronchioles
Alveolar ducts
Alveoli

Question 17

What do the segmental bronchi (tertiary) supply?

Answer 17

bronchopulmonary segments

e.g upper, middle, lower lobes

Question 18

What do bronchioles lack?

Answer 18

cartilage

Question 19

Secondary (lobar) bronchi structural specialization

Answer 19

Plates of hyaline cartilage

Question 20

Tertiary (segmental) bronchi structural specialization

Answer 20

Pseudostratified ciliated columnar epithelium

Question 21

Terminal bronchioles structural specialization

Answer 21

Initially ciliated, then simple columnar epithelium
No cartilage, more smooth muscles
No goblet cells, no mucous

Question 22

Respiratory bronchioles structural specialization

Answer 22

Simple squamous epithelium

Surfactant producing

Question 23

Alveoli structural specialization

Answer 23

Single-cell layer of pneumocytes

Question 24

Cause of acute asthma?

Answer 24

Allergen that causes sudden inflammation and contraction of bronchiole smooth muscle (bronchospasm), narrowing the airways

Question 25

Symptoms of acute asthma

Answer 25

Difficulty breathing | Wheezing

Question 26

What type of disease in terms of genes is cystic fibrosis?

Answer 26

Autosomal recessive

Question 27

What is the pathophysiology of cystic fibrosis?

Answer 27

Deranged transport of chloride and other ions alters the viscocity of mucous Makes patient more prone to infection, damaging bronchi resulting in bronchiectasis

Question 28

Symptoms of COPD

Answer 28

``` Chronic bronchitis (mucus hypersecretion Emphysema (tissue destruction) Bronchiolitis (small airway inflammation and fibrosis) ``` Lead to resistance to airflow in airways increased compliance in lungs air trapping Progressive airflow obstruction

Question 29

What causes COPD?

Answer 29

Long term exposure to harmful particles and gases causing abnormal inflammatory response Smoking major cause

Question 30

Which arteries supply the lungs and visceral pleura?

Answer 30

Bronchial arteries 2 left bronchial arteries single right bronchial artery

Question 31

What vessels supply the parietal pleura?

Answer 31

Thoracic wall vessels

Question 32

The lymphatic drainage steps for lungs

Answer 32

1) Bronchopulmonary nodes 2) Tracheobronchial nodes 3) Pratracheal nodes 4) Bronchomediastinal lymphatic trunks 5) Thoracic duct

Question 33

Where is the larynx located?

Answer 33

In anterior neck

Question 34

Functions of larynx ?

Answer 34

Phonation- production of vocal sound + speech Cough reflex Protection of the lower respiratory tract

Question 35

How is the larynx interior surface lined?

Answer 35

Pseudostratified ciliated columnar epithelium except for vocal cord which stratified squamous epithelium

Question 36

Larynx spinal root position

Answer 36

C3-C6

Question 37

What is above and below the larynx

Answer 37

Superior pharynx | Inferiorly trachea

Question 38

3 parts of the larynx

Answer 38

Supraglottis Glottis- contains false and true vocal cords Subglottis/infraglottis- vocal folds to trachea

Question 39

Name 3 laryngeal cartilages (unpaired)

Answer 39

Epiglottis- flattens during swallowing Thyroid (C4) Cricoid (C6)- can be compressed during emergency intubation to stop regurgitation of stomach content

Question 40

Name 3 paired laryngeal cartilages

Answer 40

Arytenoid Corniculate Cuneiform

Question 41

What do vocal folds do?

Answer 41

produce speech protect airway from choking from material in throat regulate flow of air into lungs

Question 42

What is Reinke's space?

Answer 42

In true vocal cords. Watery layer. Due to fluidity, epithelium able to vibrate freely above it to create sound

Question 43

What is Rima Glottidis?

Answer 43

Space between vocal cords

Question 44

Difference between true and false vocal cords?

Answer 44

True: non-keratinized stratified squamous epithelium False: vestibular ligament covered by mucous membrane

Question 45

Similarities between true and false vocal cords?

Answer 45

Protection to larynx

Question 46

What nerve innervates the larynx?

Answer 46

Vagus nerve (Motor and sensory)

Question 47

What branch of the vagus nerve supplies the supraglottis?

Answer 47

Internal branch of superior laryngeal nerve

Question 48

What branch provides innervation to infraglotttis?

Answer 48

Inferior laryngeal nerve (continuation of recurrent laryngeal nerve)

Question 49

Which is more prone to palsy right or left recurrent laryngeal nerve?

Answer 49

Left as has a longer course- loops under aortic arch

Question 50

Damage of RLN causes

Answer 50

Apical lung tumour Thyroid cancer etc.

Question 51

Symptoms of Unilateral RLN palsy (recurrent laryngeal nerve)

Answer 51

Hoarseness Increased risk of aspiration Bovine cough

Question 52

Symptoms of bilateral RLN palsy

Answer 52

Cords adducted Breathing impaired (stridor, snoring) Phonation cannot occur

Question 53

What do the extrinsic laryngeal muscles do?

Answer 53

Elevate/superiorly or depress/inferiorly the larynx during swallowing

Question 54

What do the intrinsic laryngeal muscles do?

Answer 54

Move individual components of larynx for breathing and phonation

Question 55

What do the suprahyoid muscles do? (extrinsic)

Answer 55

Elevate the larynx

Question 56

What do the infrahyoid muscles do?

Answer 56

Depress the larynx

Question 57

How do the vocal cords produce sound?

Answer 57

Adduction of arytenoids and elongation of vocal folds closes the airway

Question 58

What do extrinsic laryngeal ligaments do?

Answer 58

attach larynx to external structures?

Question 59

What do intrinsic laryngeal ligaments do?

Answer 59

Hold cartilages of the larynx together as one functional unit

Question 60

What is cricothyroidotomy

Answer 60

Emergency procedure that provides a temporary airway in situations where there is obstruction at or above the larynx (facial trauma, oedema, foreign body)

Question 61

How to do a cricothyroidotomy

Answer 61

1) Depression below thyroid cartilage can be palpated 2) Incision made here 3) ET tube inserted to secure airway

Question 62

Vein drainage

Answer 62

Superior laryngeal vein draining to internal jugular vein and inferior laryngeal veins draining to left brachiocephalic vein

Question 63

What lymph nodes are superior to vocal folds?

Answer 63

Superior deep cervical lymph nodes

Question 64

What lymph nodes are inferior to vocal folds?

Answer 64

Pretracheal and paratracheal lymph nodes | Inferior deep cervical lymph nodes

Question 65

What does the inferior laryngeal nerve innervate?

Answer 65

Sensory innervation to Infraglottis | Motor innervation to all internal muscles of larynx except cricothyroid

Question 66

What does the superior laryngeal nerve innervate?

Answer 66

Sensory innervation to supraglottis | Motor innervation to cricothyroid

Question 67

lung blood supply

Answer 67

1 pulmonary artery 2 pulmonary veins 2 left brachial arteries 1 right brachial artery