Respiratory system II. © David Kachlík 30.9.2015 Anatomical division • 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 © David Kachlík 30.9.2015 General structure of respiratory system wall • 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 Endoscopy view of trachea © 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 © David Kachlík 30.9.2015 Tracheotomy – risks bleeding from: • plexus thyroideus impar • a. thyroidea ima (2%) • arcus venosus jugularis • lobus pyramidalis glandulae thyroideae (40%) © David Kachlík 30.9.2015 Trachea – wall structure • 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 © David Kachlík 30.9.2015 Lungs – division • 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