Lower Respiratory Tract – Larynx – Trachea – Tracheobronchial Tree – Respiratory Compartment

Respiratory system II.

• upper respiratory tract – nasal cavity – paranasal cavities – nasopharynx • lower respiratory tract – larynx – trachea – tracheobronchial tree – respiratory compartment

© David Kachlík 30.9.2015 Anatomical Surgical division division • upper respiratory tract • upper respiratory tract – nasal cavity – nasal cavity – paranasal cavities – paranasal cavities – nasopharynx – nasopharynx – larynx

• lower respiratory tract • lower respiratory tract – larynx border: apertura thoracis sup. – trachea – trachea – tracheobronchial tree – tracheobronchial tree – respiratory compartment – respiratory compartment

• tunica mucosa (mucosa) – epithelium - ciliated pseudostratified columnar (respiratory epithelium) - non-keratinized stratified squamous - lamina basalis – lamina propria • glands (seromucinous tuboalveolar), lymph nodes (noduli lymphoidei) • tunica fibromusculocartilaginea – collagenous and elastic tissue (and its ligaments – larynx, trachea) – smooth muscles (trachea, bronchi, bronchioli) – skeletal muscles (larynx) • tunica serosa or tunica adventitia – tunica serosa (pleura) has three layers: • mesothelium – lamina basalis • lamina propria • tela subserosa © David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Trachea

• pars cervicalis (C6- C7) • pars thoracica (T1-T4) newborn at the level of C4, child C5 • bifurcatio tracheae (T4) = 1st branching of tracheobronchial tree • carina tracheae • calibers: length 10-11 cm, width 25 mm • syntopy: ventrally thyroid gland, dorsally

oesophagus © David Kachlík 30.9.2015 TRACHEA Pars cervicalis Pars thoracica Cartilagines tracheales M. trachealis Ligg. anularia / trachealia Paries membranaceus Bifurcatio tracheae Carina tracheae

© David Kachlík 30.9.2015 Trachea – supply • Arteries: – a. thyroidea inf. → rr. tracheales – aorta thoracica → rr. bronchiales – (a. thyroidea ima – 2 %) – newborns and children – branches from thymus arteries • Veins: – drain into oesophageal veins, into plexus thyroideus impar and into v. brachiocephalica sin. • Lymph: – nodi tracheobronchiales, nodi tracheales → truncus bronchomediastinalis dx.+ sin. • Nerves: – n. vagus → n. laryngeus recurrens – truncus sympathicus © David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Coniotomy (coniopuncture) emergency procedure in outdoor (rare) transversal section between cartilago thyroidea et cricoidea through lig. cricothyroideum medianum Approach passes through following layers: • skin + subcutaneous tissue • lamina superficialis fasciae cervicalis • lamina pretrachealis fasciae cervicalis • lig. cricothyroideum medianum + mucosa !Cave! – interconnection of rr. cricothyroidei a. laryngeae superioris below cartilago thyroidea

– lobus pyramidalis© David Kachlík glandulae 30.9.2015 thyroideae (40%) © David Kachlík 30.9.2015 Tracheotomy sagittal section for canylation through several tracheal cartilages (done in hospital) • tracheostomia superior – above isthmus glandulae thyroideae (in the extent of cartilago trachealis 2-4) • tracheostomia inferior – below isthmus, above incisura jugularis Approach passes through following layers: • skin + subcutaneous tissue • lamina superficialis fasciae cervicalis • venous arcus venosus jugularis (only in lower tracheotomy) • lamina pretrachealis fasciae cervicalis + cutting through midline fibrous connection of both mm. sternohyoidei (only in lower tracheotomy) • venous plexus thyroideus impar (only in lower tracheotomy) • cartilagines tracheales + ligg. anularia + mucosa © David Kachlík 30.9.2015 • coniotomy

• upper tracheotomy

• lower tracheotomy

• epithelium of respiratory tract • glandulae tracheales – seromucous glands • cartilagines tracheales (15-20) – C-shaped rings • ligg. anularia / trachealia • paries membranaceus – dorsal wall • m. trachealis – smooth (horizontal as well as longitudinal fibers) • adventicia on the surface © David Kachlík 30.9.2015 © David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Tracheobronchial tree (Arbor bronchialis)

23 divisions – dichotomic branching • primary bronchi (bronchus pricipalis dx.+ sin.) – right: shorter, wider, straighter  foreign body enters in 75% into the right one • secondary bronchi (bronchi lobares) – 2 left and 3 right • tertiary bronchi (bronchi segmentales) – 8 on the left and 10 on the right • left: 1+2 connected, 7+8 connected in 90% • exception: 6th bronchus segmentalis of both sides branches in trichotomi© David Kachlíkc way 30.9.2015! © David Kachlík 30.9.2015 Tracheobronchial tree (Arbor bronchialis)

• bronchi 4th order (bronchus subsegmentalis): b = ventral, a = dorsal • bronchi 5th order: ii = ventral, i = dorzal • bronchi 6th order: β = ventral, α = dorzal  • terminal bronchioli (bronchiolus terminalis) = 14th-16th order (originate by 14th division) 1 bronchiolus terminalis = 1 secondary pulmonary lobulus (visible on the lung surface)  alveolar tree (originate by 17th branching) © David Kachlík 30.9.2015 Bronchi (Bronchi) tunica mucosa: • epithelium of respiratory tract pseudostratified  columnar with cilia • seromucous glands tunica fibromusculocartilaginea: • cartilages have irregular shape (more peripheraly disappear) • smooth muscle – spiral (more peripheraly increases) • nodes of lymphoid tissue – at the branching

© David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Bronchioli (Bronchioli) • caliber < 1 mm • epithelium changes into simple cuboidal • exocrinocyti bronchiolares (Clara cells) – produce constituents of surfactant, lysosomal activity, mitotic activity • no cartilage, glands and lymph nodes • increase of elastic fibers • 1 bronchiolus terminalis = 1 secondary pulmonary lobule © David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Lungs (Pulmo) description: basis, apex • facies costalis (+ pars vertebralis) • facies mediastinalis (+ impressio cardiaca) • facies diaphragmatica • (facies interlobaris) • margo anterior (incisura cardiaca p.sin.) • margo inferior • hilum pulmonis, radix pulmonis • fissura obliqua, fissura horizontalis p. dx. • impressions © David Kachlík 30.9.2015 RIGHT LUNG LEFT LUNG

• hilum (clinically hilus) – structures: left „ABV“ - right „BAV“ • right lung – 3 lobes (sup., middle, inf.) • left lung – 2 lobes (sup., inf.) – lingula p. sin. • segments (segmenta bronchopulmonalia) – 10 on the right – 10 on the left (sometimes 8) • I+II fused, VII missing in 90% © David Kachlík 30.9.2015 HILUM PULMONIS Left lung Right lung

A B B A V V

© David Kachlík 30.9.2015 Lungs – impressions • sulcus arteriae subclaviae (facies mediastinalis) • impressio costae primae (margo anterior) • impressiones costarum (facies costalis) • impressio cardiaca (facies mediastinalis) Left lung: all on facies mediastinalis • sulcus aorticus • impressio oesophagea • sulcus venae brachiocephalicae sinistrae Right lung: all on facies mediastinalis • sulcus venae cavae superioris • sulcus venae azygos (!correctly s.v. azygoi !) © David Kachlík 30.9.2015 • sulcus oesophageus Segments

right lung (apalmsmalp) left lung (apasismalp) Abb. Segmentum No. of Lobe Abb. Segmentum No. of Lobe segment segment A apicale I upper AP apico- I + II upper posterious P posterius II A anterius III

A anterius III S lingulare IV superius L laterale IV middle I lingulare V M mediale V inferius S superius VI lower S superius VI lower M basale VII M basale VII mediale mediale

A basale VIII A basale VIII anterius anterius

L basale IX L basale IX laterale laterale

P basale X P basale X posterius © David Kachlík 30.9.2015posterius Lung segments

© David Kachlík 30.9.2015 Segmenta bronchopulmonalia Pulmo dexter, lobus superior Segmentum apicale [S I] Segmentum posterius [S II] Segmentum anterius [S III] Pulmo dexter, lobus medius Segmentum laterale [S IV] Segmentum mediale [S V] Pulmo dexter, lobus inferior Segmentum superius [S VI] Segmentum basale mediale; Segmentum cardiacum [S VII] Segmentum basale anterius [S VIII] Segmentum basale laterale [S IX] © David KachlíkSegmentum 30.9.2015 basale posterius [S X] Segmenta bronchopulmonalia Pulmo sinister, lobus superior

Segmentum apicoposterius [S I+II]

Segmentum anterius [S III]

Segmentum lingulare superius [S IV]

Segmentum lingulare inferius [S V] Pulmo sinister, lobus inferior

Segmentum superius [S VI] Segmentum basale mediale; Segmentum cardiacum [S VII]

Segmentum basale anterius [S VIII]

Segmentum basale laterale [S IX] © David Kachlík 30.9.2015 Segmentum basale posterius [S X] Blood supply of lungs – functional circuit

• right heart ventricle (deoxygenated blood) → truncus pulmonalis → arteria pulmonalis dx.+ sin. → branching correspond to bronchi – left hyparterial bronchus, right eparterial bronchus • elastic arteries – low-pressure vasculature 25/5 Torr – smooth muscle cells in fetus, in adults since < 1 mm → capillaries (continuous) → oxygenated blood → venules independent on arteries in septa between lobules → 4 venae pulmonales (2 right and 2 left) → left heart atrium © David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Blood supply of lungs functional circuit

• arterio-venous anastomoses • arterio-arterial anastomoses • veno-venous anastomoses

• during hypoxia fastly growing arterial smooth muscle → hypertrophy of right ventricle

• aorta thoracica → rami bronchiales – 1 right – usually from a. intercostalis tertia – 2 left – directly from thoracic aorta → along bronchi as far as bronchioli respiratorii – (rami bronchiales accessorii within lig. pulmonale)

• venae bronchiales – deep system opening into vv. pulmonales – superficial system drains blood from extrapulmonary bronchi, pleura and hilar lymphnodes → vv. pulmonales or v. azygos / hemiazygos accessoria © David Kachlík 30.9.2015 Lungs – lymph drainage • superficial subpleural plexus • deep plexus around bronchi and vessels Lung alveoli have no lymph vessels in their walls • nodi lymphoidei intrapulmonales → n.l. bronchopulmonales → n.l. tracheobronchiales inferiores (both lungs except of three left upper segments I+II, III) → n.l. tracheobronchiales sup. dx. → truncus bronchomediastinalis dx. → angulus venosus dx. → v. brachiocephalica dx. I+II, III segments on the left – directly into n.l. tracheobronchiales sin. → truncus bronchomediastinalis sin. → ductus thoracicus → angulus venosus sin.© David → Kachlíkv. 30.9.2015brachiocephalica sin. © David Kachlík 30.9.2015 Lungs – innervation

• nn. vagi both sides viscerosensory + autonomic parasympathetic stimuli

• truncus sympathicus autonomic sympathetic stimuli

• dichotomic branching • from bronchioli respiratorii onwards • 17th-23rd order • functionally respiratory compartment

© David Kachlík 30.9.2015 Tracheobronchial tree (Arbor alveolaris) • respiratory bronchioles (bronchioli respiratorii) 17th-19th order (originating by 17th branching) – pulmonary alveoli evaginate from their walls – 19th order forms lobulus pulmonis primarius (8 primary lobuli together form one secondary) • alveolar ducts (ductus alveolares) 20th-22nd order – pulmonary alveoli evaginate from their walls – at the end of 3rd orderalveolar duct there is atrium (atrium), divided by last, 23rd branching into two:  • alveolar saccules (sacculi alveolares) 23rd order – evaginate only into: • pulmonary alveoli© David(alveoli Kachlík 30.9.2015 pulmonis) Respiratory bronchioli Bronchioli respiratorii

• diameter < 0,3 mm • simple ciliated cuboidal epithelium • branching of pulmonary alveoli • continue into alveolar ducts

© David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Lung alveoli Alveoli pulmonis • 200 μm size, polyedric, thin-walled • alveolar mucosa = respiratory epithelium • alveolar septum • alveolar pores (Kohn)

© David Kachlík 30.9.2015 Alveolar mucosa • pneumocytus typus I (pneumocyte type I, type I alveolar cell; membranous p.) • 95% of mucosa • flat, thin (25 nm) • organels around nucleus • pinocytic vesicles • pneumocytus typus II (pneumocyte type II, type II alveolar cell; granular, spetal, great alveolar cells) • ovoid shape with microvilli • secretory structure (Mit, GER, GA) • lamellar bodies (1,5 μm) = surfactant • proliferate and© differentiateDavid Kachlík 30.9.2015 (recovery of mucosa) © David Kachlík 30.9.2015 Interalveolar septum Septum interalveolare

• cells • fibroblasts (collagen type I and III) – septum cells • endothelial cells of capillaries • alveolar macrophages (macrophaygocyti alveolares) • reticular and elastic fibers • alveolar pores (pori septales) – 10 μm

© David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Blood – air barrier (Claustrum aerosanguineum) • alveolar component (alveolar cell layer, lamina pneumocytica) – pneumocytes type I • basal lamina (lamina basalis) • endothelial layer (lamina endotheliocytica) – endothelial cells of capillaries

• Whole respiratory surface of lungs = 140 m2 (almost two volleyball grounds )

• surface-active-agent • lowers surface tension of pulmonary alveoli • prevents from collapsing during expiration • watery hypophasis and lipid epiphasis (dipalmitoyl lecithin) • resorption and recovery by alveolar cells • enters into respiratory tract → bronchoalveolar fluid © David Kachlík 30.9.2015 Defense mechanisms • nasal apertures – mucus, nasal cartilages, hairs of veostibule of nose (vibrissae) • ciliated epithelium (mucocilliary transport) • alveolar macrophages (= dust cells) • lymph nodes in the wall • intra-epithelial dendritic cells • T and B lymfocytes (IgA) • antimicrobial substances in mucus (lysosym, defensins, surfactant protein A,D)

• inspection, percussion, auscultation, palpation • X-ray, CT • bronchoscopy (rigid, flexibile) • bronchography • spirometry (vital capacity of lungs)

• atelectasis • embolia • bronchiectasis • fibrosis • lung oedema • RDS (IRDS), ARDS • emphysema • tumors, inflammations (e.g. TBC) © David Kachlík 30.9.2015 Kartagener syndrome

• missing movement of cilia • molecular defect in ciliar mobility apparatus • chronic pyogenic rhinitis and sinusitis • bronchiectasis

• insufficient hydration of mucous layer → increased viscosity • decrease of periciliary layer of fluid → missing free space for ciliar movement → mucus rests directly on epithelium • clogging of bronchi with mucus → chronic inflammation + bronchiectasis → respiratory insufficiency

• squamous cell carcinoma – effect of smoking – arises from metaplasis of respiratory epithelium into non-keratinized stratified squamous • small cell lung carcinoma – very malign tumor • neuroendocrine tumor (carcinoid) – may be hormonally active

• pleura visceralis • pleura parietalis – pars costalis, diaphragmatica, mediastinalis

• cupula pleurae – reinforced by membrana suprapleuralis Sibsoni – lig. scalenopleurale, lig. vertebropleurale, transversopleurale + m. scalenus minimus Sibsoni, lig. costopleurale • recessus pleurales: – costodiaphragmaticus (puncture) – costo-, phrenico- a vertebromediastinalis • lig. pulmonale • cavitas pleuralis • liquor pleurae • pneumothorax (external x internal) © David Kachlík 30.9.2015 Pleura

© David Kachlík 30.9.2015 Parietal pleura – supply Arteries: • a. subclavia → a. thoracica interna → a. musculophrenica + aa. intercostales ant. • aorta thoracica → aa. intercostales post. Veins: thoracic wall veins Lymph: n.l. intercostales, parasternales, diaphragmatici, mediastinales posteriores Nerves: • nn. intercostales (pleura costalis + peripheral pleura diaphragmatica) • n. phrenicus (pleura mediastinalis + central pleura diaphragmatica) © David Kachlík 30.9.2015 Pleura visceralis – supply

• corresponds to lung supply arteries: rr. bronchiales veins: vv. bronchiales lymph: see lungs nerves: only autonomic nerves around vessels, around hilum from n. vagus

!!! Visceral pleura is not painfull !!!

• projection of lungs 1-2 intercostal space higher lower compared to pleura • 10 lines on thorax • area interpleuralis superior (thymus) • area interpleuralis inferior (heart) puncture: 7.-8. intercostal space in posterior axillary or scapular line by upper costal margin © David Kachlík 30.9.2015 Projection of lungs and pleura

• inspiratory – main: diaphragm, mm. intercostales externi, (mm. scaleni, mm. levatores costarum) – auxiliary: m. pectoralis major + minor, m. latissimus dorsi, m. serratus anterior + post. sup., m. sternocleidomastoideus, m. subclavius, (m. sternothyroideus, m. sternohyoideus) – orthopnoic posture • expiratory – main: mm. intercostales interni (+ intimi, m. subcostales) – auxiliary: m. rectus abd., m. obliquus abd. ext. + int., m. trasnversus abd., m. serratus post. inf., m. transversus thoracis, (m. quadratus lumborum), m. levator ani

• anatomical division: – upper – lower (anterior, middle, posterior)

• surgical division (many ): e.g. – anterior – posterior

© David Kachlík 30.9.2015 © David Kachlík 30.9.2015 Mediastinum superius structures in 5 layers ventrodorsally: 1. thymus, insertions of mm. sternothyroideus et sternohyoideus, vasa thoraciaca int. + branches 2. layer of veins: vv. brachiocephalicae (plexus thyroideus impar, v. intercostalis sup. sin.) join ito v. cava sup., ductus thoracicus, nn. phrenici 3. layer of arteries: arcus aortae + branches 4. organs: trachea + bifurcation (at level of vertebra T4), bronchi principales, oesophagus + nn. vagi, rr. cardiaci, n. laryngeus reccurens sin., nodi lymphoidei tracheobronchiales, nodi lymphoidei paratracheales, membrana bronchopericardiaca 5. truncus sympathicus dx. et sin., nn. cardiaci, nodi lymphoidei © David Kachlík 30.9.2015 juxtaesophageales, m. longus colli Mediastinum inferius Mediastinum inferius anterius • ligg. sternopericardiaca • nodi lymphoidei parasternales, prepericardiaci (= "n.l. mediastinales posteriores") • vasa thoracica int. + branches • m. transversus thoracis Mediastinum inferius medium • heart in pericardium • aorta ascendens + truncus pulmonalis • v. cava sup., v. cava inf. (+ ostium of v. azygos) • nn. phrenici, vasa pericardiacophrenica • plexus cardiacus • vv. pulmonales • nodi lymphoidei pericardiaci laterales Mediastinum inferius posterius • oesophagus + plexus oesophageus • truncus symphicus + nn. splanchnici (major, minor, imus) • nodi lymphoidei prevertebrales, juxtaesophageales (= "n.l. mediastinales posteriores") • ductus thoracicus • v. azygos, hemiazygos et hemiazygos accessoria (+ tributaries) © David Kachlík 30.9.2015 • aorta thoracica + branches Mediastinum posterius