Lecturer: Ms DS Pillay ROOM 2P24 25 February 2013 Thoracic Wall Consists of thoracic cage Muscle Fascia Thoracic Cavity 3 Compartments of the Thorax (Great Vessels) (Heart) Superior thoracic aperture Intercostal space Intercostal vasculature Internal thoracic A Anterior thoracic A Musculophrenic A Posterior intercostal A Superior intercostal A Thoracic aorta Subcostal a. Veins Internal thoracic vein: internal surface of ribs, lateral to sternum, drains into brachiocephalic v. Anterior thoracic vein: anteriorly between ribs to drain into internal thoracic v. Posterior intercostal veins: travel posteriorly between ribs, 1st 3 join to form superior intercostal v. Drain into brachiocephalic system, remaining drain azygous system Intercostal Nerves They are anterior primary rami of spinal thoracic nerves fromT1 to T11 T3 toT6 are Typical T12 is called Subcostal The remaining nerves are called atypical Each nerve runs in Intercostal space inferior to Intercostal vessels Chest Tube Placement Thieme Cl. 5.200A Pleural Membranes PARIETAL PLEURA VISCERAL PLEURA PLEURAL CAVITY (SEROUS FLUID) Parietal Pleura: four parts Cervical (cupular) costal mediastinal diaphragmatic Why do you tend to feel pain in the parietal pleura and not the visceral pleura? Cervical pleura Extends up into neck Lines undersurface of suprapleural membrane Reaches level of 2.5-4cm above medial 1/3 of clavicle Costal pleura Lines inner surface of Ribs Intercostal spaces Costal cartilage sides of vertebral bodies Back of sternum Diaphragmatic pleura Covers thoracic surface of diaphragm Costodiaphragmatic Recess Slit-like space between costal & diaphragmatic parietal pleaura During inspiration, lower margins of lungs descend into recesses During expiration, lower margin of lungs ascend so that costal & diaphragmatic pleurae come together Mediastinal pleura Covers & forms lateral boundary of mediastinum Continuous with visceral pleura Lungs lie free except at hilum Costomediastinal Recesses Along anterior margins of pleura Slit-like spaces between costal & mediastinal pleurae During inspiration & expiration, anterior borders of lungs slide in & out of recess Blood, Nerve & Lymphatic drainage of pleura Parietal Pleura Visceral Pleura Blood 1. post intercostals 1. bronchial art Supply 2. int thoracic 3. sup intercostals 4. sup phrenic art Nerve 2nd to 12th i/c n symph fibres from T2 to Supply sensory fibres only T5 (pain sensitive) (pain insensitive) phrenic n Lymphatic drain into adj LN on thoracic drain into LN at hilum of Drainage wall lungs (axillary nodes) Features of Right & Left Lung Lobes & fissures : surface anatomy --------------------------------------------------- - Oblique fissure: extends from level of spinous process of T2 vertebra posteriorly to 6th costal cartilage anteriorly. - Horizontal fissure: begins from anterior border at level of 4th costal cartilage, runs horizontally to meet oblique fissure at the midaxillary line -------------------------------------------------------------------------------------------- RT lung LT lung -------------------------------------------------------------------------------------------- - Fissures 2 ( oblique & horizontal) 1 (oblique ) - Lobes 3 ( superior, middle & inferior) 2 (superior & inferior ) - Cardiac notch absent present - Lingula absent present - Width wider narrower - Length shorter longer - Base more concave less concave - Hilum contains 2 bronchi contains one bronchus Oblique Fissure Inferior Lobe Left Lung Lateral View Superior Lobe Oblique Fissure Left Lung Medial View Lingula Inferior Lobe Pulmonary Artery Bronchi Pulmonary Veins The Hilum Right Lung Lateral Superior Lobe View Horizontal Fissure Middle Lobe Oblique Fissure Inferior Lobe Right Lung Medial View Superior Lobe Middle Lobe Inferior Lobe The Hilum Bronchi Pulmonary Artery Pulmonary Vein Pulmonary Ligament Making an Impression Left Lung Right Lung Heart Heart Aortic arch Azygous Vein Thoracic Aorta Inferior Vena Cava Esophagus Esophagus Left Subclavian artery and vein Superior Vena Cava Right Subclavian artery and vein Medial Views of the Lungs left right groove for azygos vein left pulmonary pulmonary pulmonary veins arteries arteries bronchii right pulmonary veins groove for esophagus groove diaphragmatic for aorta cardiac recess impression Surface Anatomy Lower border of the lung: Midclavicular line rib 6 Pleura rib 8 Midaxillary line rib 8 Pleura rib 10 • Adjacent to vertebral column rib 10 Pleura rib 12 The anterior borders of lungs lie adjacent to the anterior line of parietal pleura reflection as far as the 4th costal cartilage The left line of pleural reflection moves laterally & inferiorly at cardiac notch to reach level of 6th costal cartilage Posterior border of the lung: C7 – T10 The difference between the lower border of the lung and the lower border of the pleura indicates the costodiaphragmatic recess distance Trachea R & L principal bronchus Lobular bronchi (secondary) (2L and 3R) Segmental bronchi (tertiary) (8L, 10R) Terminal bronchioles Respiratory bronchioles Alveolar ducts Alveolar sacs Alveoli Bronchopulmonary segment Right main bronchus R upper lobe bronchus R middle lobe bronchus R lower lobe bronchus Segmental bronchi Segmental bronchi Segmental bronchi Apical Medial Apical Anterior Lateral Anterior Posterior Posterior Medial Lateral Bronchopulmonary segment Left main bronchus L upper lobe bronchus L lower lobe bronchus Segmental Upper branch Lower branch Apical Anterior Anterior Superior lingular Posterior Apicoposterior Inferior lingular Lateral Arterial supply of lungs Pulmonary arteries -Give rise to lobar arteries Bronchial arteries – supply blood for nutrition of structures that comprise the root of the lung Venous drainage of lungs Pulmonary veins – -Lobar veins drain into pulmonary veins Bronchial veins – drain blood in lungs supplied by bronchial arteries -Left bronchial vein - accessory hemiazygos vein (usually) -Right bronchial vein - azygos vein Innervation of lungs Lungs and visceral pleura -Parasympathetic – from Vagus nerve -Sympathetic – from sympathetic fibers of sympathetic trunk Parietal pleura – from intercostal and phrenic nerves THANKS .