Right lung. -fissures:

Transcription

1 -Right lung is shorter and wider because it is compressed by the right copula of the diaphragm by the live.. 2 fissure, 3 lobes.. hilum : 2 bronchi ( ep-arterial, hyp-arterial ), one artery mediastinal surface with venous blood ( svc, ivc ) -Left lung is longer and thinner.. 1 fissure, 2 lobes 1 bronchi.. mediastinal surface with arterial blood ( arch of aorta, descending aorta ) Right lung -fissures: Oblique fissure : 4 cm to right side on the dorsal surface at the level of t3 or t4 then it descends obliquely to the 6 th rib anteriorly Horizontal fissure : at the level of the 4 th costal cartilage, it passes horizontally to the 6 th rib, where it meet with the oblique fissure -the 1 st rib always makes an impression on the costal surface -Hilum : pulmonary artery, 2 bronchi, 2 pulmonary veins ( sup. And inf. ), lymph nodes, bronchial vessels, autonomic nerves.. sup. Pulmonary vein is above and ant. To the inf. Pulmonary vein -impressions : 1- SVC 2- IVC *subclavian artery and vein ( on the sup. Lobe ), left and right brachiocephalic have impression but we can't feel it 3- arch of azygos.. the only part of the azygos that can be felt.. other parts are covered by the esophagus 4- esophagus.. post. To the hilum.. start from the apex *esophagus at the level of the apex is found in the mid line so it makes an impression on both right and left side, but then it's deviated to the right so it makes impression on the right lung only 5-1 st rib.. on the ant. Border 6- pericardium covering the right atrium

2 7- trachea.. from apex to the hilum Left lung : -Hilum (between t5 t7 ) : 1 bronchus, 1 pulmonary artery, 2 pulmonary veins - it contains cardiac notch ( between 4 th costal cartilage and 6 th costal cartilage ), lingual -mediastinal impressions : 1-1 st rib 2- left brachiocephalic vein 3- left subclavian artery 4- left common carotid artery 5- arch of aorta.. above the hilum 6- descending aorta.. behind the hilum 7- esophagus.. directly behind the hilum.. ant. To the descending aorta *in the lower half of the thorax it will be deviated from the right side to the left side(cross the descending aorta anteriorly ) so it can enter it's opening through the diaphragm ( 1 inch to the left side at T10 ) 8- pericardium of the left ventricle *the brachiocephalic artery between the two lungs so it doesn't make any impression on the lungs. * the left subclavian is more post to the left common carotid and it's impression is more clear *vagus nerve, phrenic nerve, pericardiophrenic vessels make impression on both lung but very small impressions

3 Pulmonary arteries (left and right ) : -from the pulmonary truck - right branch is longer - in the hilum the left pulmonary artery is above the bronchus, ant. To the sup. Pulmonary vein -the right pulmonary artery is divides into 2 branches ( upper and lower ).. sup. Pulmonary vein is ant. To the lower branch - bifurcation of the pulmonary trunk at the level of T4 to the left of the mid line.. anteroinferiorly to the bifurcation of the trachea - right pulmonary artery relations : Anterior to the : svc, ascending aorta, right sup. Pulmonary vein Posterior to the right main bronchus -left pulmonary artery relation : Anterior to the descending aorta Posterior to the sup. Pulmonary vein Passes through the roof of the left hilum Pulmonary veins (4 in number ) : -ant. to the pulmonary arteries -from the lung to the left atrium Bronchial arteries : -gives the nutritive blood supply to the lung, pleura, all lung tissues - right bronchial artery from the 3 rd post. Intercostal artery from the descending aorta - left bronchial arteries directly from the ant. surface of the thoracic descending aorta

4 - sup. Left bronchial artery at the level of T5, and the inf. One inf. To the left bronchus -the bronchial arteries run on the post. Surfaces of the bronchi and ramify in the lungs to supply pulmonary tissues Bronchial veins : -drains into the pulmonary veins to the left atrium or to the azygos on the right side and hemiazygos on the left side Innervations : -by autonomic nerves -vagus nerve and sympathetic sup. Cervical ganglia they make ant. and post. Pulmonary plexus ( at the end of the bronchia ) and esophageal plexus -ant. plexus is smaller than the post. - parasympathetic cause bronchoconstricion Sympathetic cause bronchodilation -important in spring.. because it can induce allergy to many people which cause asthma Lymphatic drainage : -superficial lymphatic plexus which is deep to the pleura, on the surface -deep lymphatic plexus -these lymph nodes drain to the trachiobronchial lymph nodes then to the Para-bronchial lymph nodes then to the brachiocephalic lymph nodes then either to the right lymphatic duct or to the thoracic duct on the left side, they end at the bifurcation of the internal jugular vein and the subclavian ( beginning of brachiocephalic vein )

5 PLEURA : -visceral and parietal.. in between is a potential space filled with serous fluid for lubrication -parietal is lining the thoracic wall.. visceral is adherent to the lung tissue -inflation of the lung will reach the parietal -inflation mostly happen in the lower surface and lower border which makes filling of the recesses *surface anatomy of the lung and pleura: -for apex and ant./post. border is the same - the difference in the base : Lung anteriorly 6 th costal cartilage.. mid clavicular 6 th costal cartilage.. mid axillary 8 th costal cartilage.. posteriorly 10 th Pleura.. anteriorly 7 th CC.. mid clavicular 8 th CC.. mid axillary 10 th CC.. posteriorly 12 th CC Then there's 2 spaces difference between base of the lung and base of the pleura Function of the pleura : 1-protection 2-produces fluid for lubrication -Failure to function results in difficult painful breathing -Pleuritis.. is inflammation of the parietal pleura.. painful because parietal pleura is sensitive to pain and touch while visceral pleura is insensitive because it s supplies by autonomic nervous system

6 Pleural cavity : -pneumothorax : air in the pleural cavity by stabbing the thorax piercing the pleura which will collapse the lung.. treatment by inflation of the lung and suturing the wound - pleural effusion : fluid in the pleural cavity.. which can happen spontaneously or by some diseases that cause lung congestion.. the fluid will go to the recesses... treatment by aspiration through tube -empyema : pus in the pleural cavity.. after inflammation like pleuritis -haemothorax : blood in the pleural cavity.. after stab wound.. treatment aspiration *names given to the parietal pleura : 1-cervical pleura : covering the apex.. there's membrane superior to this pleura called suprapleural membrane (Sibson's fascia.. for ceiling the apex of the thoracic cavity, so it conserve the pressure inside the pleural cavity ) -Closure of the thoracic cavity downward by the diaphragm and upward by the suprapleural membrane 2-diaphragmatic pleura : above the diaphragm 3- mediastinal pleura : at the mediastinal surface *visceral and parietal pleura confuse at the mediastinal surface.. and surround the hilum.. makes the pulmonary ligament 4- costal pleura : at the costal surface Suprapleural membrane ( Sibson's fascia ) : *Sibson's fascia is called fascia because it blends with the deep fascia of the root of the lung which will help the ceiling of the pleural cavity -it's fibrous sheath

7 -laterally it's attached to the medial border of the 1 st rib and costal cartilage -medially it blends with the deep fascia ( investing deep fascia ) at the root of the neck -apex is attached to the tip of the 7 th cervical vertebra at the transverse process -function : 1- it protect the cervical pleura and lung 2- resist changes in intrathoracic pressure during inspiration which means that the apex is sealed completely *visceral pleura : - continuous with the parietal at the hilum - firmly attached to the surface of the lungs - supplied by autonomic nerves *pleural recesses : - recesses : is the angle at the lower border - costodiaphragmatic recess : is the angle between the costal surface and the diaphragmatic surface - costodiaphragmatic recesses is the largest and clinically the most important recess *relationship of the pleura reflections and the lobes of the lung : - at the midclavicular line, the recess is between the 6 th and the 8 th intercostals spaces - at the midaxillary line, the recess is between the 8 th and the 10 th intercostals spaces - at the paravertebral line, the recess is between the 10 th and the 12 th intercostals spaces

8 *Costodiaphragmatic recess : - 1 inch in the midclavicular line - 2 inches in the scapular line post. - 3 inches in the midaxillary line *aspiration of fluid ( pneumothorax, pleural effusion ) from the pleural cavity by putting a needle through the 7 th intercostal space in the midclavicular line or the 9 th intercostal space midaxillary line (best) or postteriorly in the 11 th intercostal space. - the needle should be put in the lower border of the space ( upper border of the rib ) to be away from the intercostal artery, vein and nerve, because they're found in the costal groove at the lower border of the rib *pleural effusion : - usually the pleural space contain 5-10 ml of clear fluid - absorbed normally by the visceral pleura - pleural effusion is the accumulation of excess fluid in the pleural cavity, pleural fluid increases more than 300 ml in the costodiaphragmatic recess - it could be increased spontaneously or by infection or injury ( trauma ) - clinical manifestations : 1- decrease in the lung expansion 2- decrease breath sound 3- there's dullness in percussion ( in pleural effusion, empyema, haemothorax but not in pneumothorax ) 4- pain 5- cough

9 *nerve supply to the pleura : *parietal pleura : it s sensitive to pain, temperature, touch By : 1- intercostal nerves to the costal pleura 2- phrenic nerve to the mediastinal and diaphragmatic pleura 3- lower 6 intercostal nerves to the peripheral pleura *costal pleura is innervated segmentally which means that the pleura in the 6 th intercostal space is innervated by 6 th intercostal nerve while cervical pleura is innervated by the 1 st and 2 nd intercostal nerves. *visceral pleura : - is sensitive to stretch only - supplied by pulmonary plexus **arterial supply of the pleura : *parietal pleura from the arteries that supply the thoracic wall : 1- intercostal arteries ( ant & post ) 2- internal thoracic 3- musculophrenic arteries *visceral pleura from the bronchial arteries ** venous drainage of the pleura : into the azygos and internal thoracic veins

10 ** lymphatic drainage of the pleura : *parietal pleura : -mediastinal pleura : 1- mediastinal nodes 2- tracheobronchial nodes to parabronchial nodes 3- intercostal nodes -diaphragmatic pleura : 1- parasternal nodes 2- post. Mediastinal nodes -all these nodes drains into the thoracic duct or right lymphatic duct *visceral pleura : Along the bronchial arteries to the bronchopulmonary nodes.