1. Lower Respiratory Tract Anatomy

2. Thoracic wall arterial supply: Posterior intercostal arteries  Descending aorta Anterior intercostal arteries  Internal thoracic artery Importance of anastomoses? Collateral circulation to get around blockage e.g. aortic coarctation See widened costal margins on CXR (dilated intercostal arteries)

3. Thoracic wall venous drainage Intercostal veins ultimately drain into:  Hemiazygous vein  Accessory hemiazygous vein  Azygous vein  Internal thoracic veins Drain into:  Brachiocephalic vein (upper spaces)  SVC Azygous vein Intercostal veins Hemiazygous vein Accessory hemiazygous vein

4. Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy 2cc 6cc 6rib MCL 8 rib MAL Apex sits ~2cm above medial 1/3 of clavicle Horizontal fissure: 4 th cc horizontally back to oblique fissure Oblique Fissure: T3 Spinous Process to 6 th cc anteriorly Lung Surface Markings

5. Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy 8 rib MCL 10 rib MAL 6cc Pleural Markings Marks the point of reflection of parietal pleura from the thoracic wall. Costodiaphragmatic recess = region between lung and pleura.  Liver biopsy…patient inhales or exhales?  Exhale! Extend the gap between the lungs + pleura.  Reduces risk of complications.

6. Trachea originates at what vertebral level? C6 (continuation of cricoid cartilage) Bifurcates at what vertebral level? T4 / T5 More likely to aspirate into which bronchus? Why? Right…more vertical, foreign body / gastric contents more likely to fall this way. Why’re you worried about a flattened angle at the carina? Lymph nodes inferior to carina…consider lung tumour!

7. What three things does the smallest functional unit of the lungs need (bronchopulmonary segments)? Air supply. Venous drainage. Arterial supply. Each segment is separated by fibrous tissue. Pulmonary veins: Run between segments. Oxygenated blood. Pulmonary artery: Run with bronchi + bronchioles (need to for gas exchange)! Deoxygenated blood. Pulmonary vein Pulmonary artery Segmental 3° bronchus

8. Where does the diaphragm attach? Diaphragm is a muscular & tendinous structure that domes into the thoracic cavity What is the diaphragm? The Diaphragm + External intercostals + Scalenes/ sternocleidomastoid Tom Grant is 26 year old man with two lungs. What provides the driving force for inspiration when Tom is breathing?

9. Diaphragm attaches to costal margin & ribs 10-12 Diaphragmatic crura attach to lumbar vertebrae Central tendinous part for heart

10. A 35 year old man presents with dyspnoea that is worse on exertion and when lying down. His ECG is normal. He is a non-smoker, his lungs are clear and he has denies any recent trauma or accidents. a) Angina b) hemi-diaphragmatic paresis c) Chest wall muscle strain d) COPD e) Anaemia The injury has cause him Atelectasis, what is Atelectasis? -Incomplete expansion of the lungs -Diminishing volume affecting all or part of a lung -Obstructive/ non-obstructive/ postoperative -Obstructive due to obstruction of air flow between trachea and alveoli -Non-obstructive due to loss of contact between visceral and parietal pleura

11. What nerve supplies the diaphragm? Diaphragm innervated by phrenic nerve (C3,4,5) for motor and sensory Additional sensory innervation on the periphery from intercostal nerves Which one of these is normal? Why?

12. What three important structures pass through the diaphragm? Vena cava thoracic-abdominal aorta oesophagus Which vertebral level do they pass through the diaphragm? Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy Vena Cava – T8 Oesophagus – T10 Descending Aorta – T12

13. Rosie is 75 year old obese ex-weightlifter with 3 children who experiences burning chest pain after meals. After being encouraged by her husband bob to visit her GP, the GP refers her for a CXR what might they find? Hiatus hernia Herniation of stomach through the diaphragmatic oesophageal hiatus Mostly asymptomatic GORD most likely complication More likely in women who have given birth, obese people, increasing age Bob prompting Rosie to visit the GP is called sanctioning and is one of the triggers to seek help known as the ‘lay referral’ system. What are 4 other triggers? Interpersonal crisis Symptoms interfering with personal and/or social relations Interference with work or physical activity A ‘temporalizing of symptomatology'

14. Gary Is in a car crash and experiences blunt trauma to this thorax, a decision is made to insert a chest drain. What is the most likely reason the chest drain is inserted in this instance? Pneumothorax To give a passage for the air inside the pleural cavity to escape What are additional indications for chest drain use? Haemothorax Pleural effusion Empyema Chylothorax (lymphatic effusion due to disruption/ obstruction of the thoracic duct) Gary is rather spiritual and believes that his life force will be sucked out from his thorax by the chest tube. His spiritualism is one form of lay belief, name 4 others Personal knowledge The media and the internet Religion Alternative and completmentary medicine Folk law Previous medical encounters

15. Triangle of safety What are the surface markings for the triangle of safety Where is a chest tube inserted? Tunstall & Shah 2012 Pocket Tutor: Surface Anatomy Posterior axillary lineAnterior axillary line Nipple line 3 RD OR 4TH ICS LATERAL BORDER OF PEC. MAJOR ANTERIOR BORDER OF LAT DORSI NOT ALWAYS ACCURATE

16. How many lobes do the lungs have? Right lung has 3 lobes and the left has 2 lobes....although this can vary What is the left lobes middle lobe called? Lingual lobe Gary lost his right middle lobe post-pneumothorax. Now identifying as disabled he became an activist for equality and learned the UK equality act, what does the UK equality act state?

17. The clinical education fellows at Warwick hospital struck up strong relationships with Gary as they used his lack of a right middle lobe to test auscultation technique on the students. What are the auscultation points of the chest that ensure all lobes are auscultated? Upper lobes – front of chest – large region to choose from (2/3 ICS) Right middle lobe – axillary region – 4 th ICS Lower lobes – posteriorly - large region to choose from