1.  Pleura & Lungs  Dr. Sarwar Hossain Khan Dr. Sarwar Hossain Khan

2. The Pleura Is a sac on either sides of the mediastinum. Are occupied by the lungs by invagination. Is a serous membrane, lined by the mesothelium. Has 2 layers—parietal & visceral layers. Is continuous with each other at the hilum of the lung. The 2 layers enclose between them the pleural cavity. This cavity is a site for—pneumothorax, pleural effusion,empyema & haemothorax.

6. Cont. Pulmonary pleura—covers the surface of lung,is free at the hilum & along the pulmonary ligament. Pulmonary pleura—covers the surface of lung,is free at the hilum & along the pulmonary ligament. Cont. with the parietal pleura. Cont. with the parietal pleura. Parietal pleura—divided into costal,diaphragmatic,mediastinal & cervical. Parietal pleura—divided into costal,diaphragmatic,mediastinal & cervical. Cervical—covers the apex of the lung & lies about 1 inch above the medial 1/3 rd of the clavical. Cervical—covers the apex of the lung & lies about 1 inch above the medial 1/3 rd of the clavical. Is covered by the sibson’s fascia. Is covered by the sibson’s fascia.

8. PULMONARY LIGAMENT Is a fold of the parietal pleura. Is a fold of the parietal pleura. Around the hilum. Around the hilum. Acts as a dead space for the expansion of the veins. Acts as a dead space for the expansion of the veins. Contains lymphatics & areolar tissues. Contains lymphatics & areolar tissues. RECESSES: are folds of the parietal pleura making room for expansion of the lungs during breathing. RECESSES: are folds of the parietal pleura making room for expansion of the lungs during breathing. Costomediastinal & costodiaphragmatic. Costomediastinal & costodiaphragmatic.

12. CLINICAL IMPORTANCE These get filled by pleural effusion when diseased. These get filled by pleural effusion when diseased. SURFACE MARKING: SURFACE MARKING: Cervical pleura Cervical pleura Anterior margin Anterior margin Inferior margin Inferior margin Posterior margin Posterior margin

14. Nerve supply Parietal — intercostal & phrenic nerves Is pain sensitive. Pulmonary pleura — autonomic nerves — sympathetic nerves. Not pain sensitive.

15. BLOD & LYMPHATIC SUPPLY Parietal—intercostal,internal thoracic and musculophrenic arteries. Parietal—intercostal,internal thoracic and musculophrenic arteries. Veins drain into azygos and internal thoracic veins. Veins drain into azygos and internal thoracic veins. Lymphatics—intercostal, internal mammary & diaphragmatic nodes. Lymphatics—intercostal, internal mammary & diaphragmatic nodes. Pulmonary pleura—bronchial arteries & bronchopulmonary nodes. Pulmonary pleura—bronchial arteries & bronchopulmonary nodes.

16. APPLIED Thoracocentesis Pleurisy Effusion Pneumothorax Haemothorax Hydropneumothorax empyema

17. THE LUNGS

18. LUNGS Organs of respiration Organs of respiration Mediastinum separates the 2 lungs Mediastinum separates the 2 lungs Spongy, grey, dark later on. Spongy, grey, dark later on. 600-700gm. R>L 600-700gm. R>L Has apex, base, 3 borders, 2 surfaces. Has apex, base, 3 borders, 2 surfaces. Apex—above the level of the anterior end of the 1 st rib—1 inch above the medial 1/3 rd end of the clavicle. Apex—above the level of the anterior end of the 1 st rib—1 inch above the medial 1/3 rd end of the clavicle. Covered by sibson,s fascia. Covered by sibson,s fascia.

19. Base — lies on the diaphragm. Anterior border is thin — vertical on the R. Ant. Border of L lung is notched — cardiac notch. Here the heart is not covered by the lung & the pericardium. Post.border is thick & corresponds to the heads of the ribs. Extend from 7 th C vert. to the 10 th T vert.

20. Inferior border—separates the base from the costal & medial surfaces. Inferior border—separates the base from the costal & medial surfaces. Costal surface. Costal surface. Medial surface—post. & anterior parts. Medial surface—post. & anterior parts. Has numerous impressions. Has numerous impressions.

21. Fissures & lobes. R Lung—3 lobes—2 fissures; oblique & horizontal. L Lung—2 lobes; 1 fissure. Oblique fissure—cuts the whole thickness of the lung, except at the hilum. Crosses post. Border, 2-3 inches below the apex. Crosses inf. Border 2 in. from the medial plane.

22. Cont. Horizontal fissure of R lobe divides the middle lobe from the upper lobe. L lobe has a lingula below the cardiac notch. No. of lobes may vary.

24. Structures related to the medial surfaces of the 2 lungs.

27. ROOTS OF THE LUNG A pedicle connecting the medial surface of the lung with the mediastinum. Short & broad. Various structures exit & enter here from & to the lungs. Lies opposite 5 th -7 th T vertebra.

28. CONTENTS

29. contents L—1-brochus, R-2-bronchi 1 PA each. 2 PV each. Bronchial art.—2 on L, 1 on R BV Pulmonary plexuses—ant,post. Lymphatics, LN, etc.

30. relations

31. Brochial tree

32. 2 bronchi branch out from the trachea. At the lower end of the 4 th T vertebra. R bronbus is short, wide,straight. Infections are common.

33. Enters lungs through the hilum. Divides into lobar bronchi—3 on R, 2 on L.

34. These further divide into—tertiary or segmental bronchi –10 on the R, 8 on the L(10) These further divide into terminal bronchioles & these into respiratory bronchioles which aerates the pulmonary unit formed by— alveolar ducts,atria, air saccules, & pulmonary alveoli.

40. Arteries,veins, lymphatics & nerve supply. Artery—bronchial art.—R side, one art.- either from 3 rd post. Intercostal or upper L bronchial art. L side-2 in no. from desc. Aorta. Pulmonary art. –deoxygenated blood. PV carry oxygenated blood to the heart.

42. veins 2 bronchial veins on each side R bronchial veins drain to azygos vein, L veins-- into hemiazygos or the superior intercostal veins. Drain blood from the 1 st 1-2 divisions of the bronchi. Rest of the blood is drained by the pulmonary veins.

46. lymphatics Bronchopulmonary nodes.—from superficial & deep vessels Some connection bet. the 2 groups exists. NERVES Parasympathetic—vagus—motor,sensory & secretomotor. Sympathetics—T2-T5—bronchodilation. Form plexuses around the hilum.

49. Bronchopulmonary segments Sector of a lung that is aerated by a tertiary bronchus. Pyramidal in shape with apex towards root. There are 10 on the R, & 8 on the L. Intersegmental planes—bet. The segments.

51. Bronchopulmonary segments Crossed by the PV. Segments have pulm. Art. With the bronchus together with the bronchial art. So the segment cannot be called a bronchovascular segment. –it has no vein.

59. Clinical Infections No barrier Surgery Postural drainage Bronchoscopy

63. MEDIASTINUM Medium septum of the thorax bet. The 2 lungs. Medium septum of the thorax bet. The 2 lungs. Ant.—sternum Ant.—sternum Post.—vert column Post.—vert column Sides --mediastinal pleura Sides --mediastinal pleura Sup.—thoracic inlet Sup.—thoracic inlet Inf.—diaphragm. Inf.—diaphragm.

65. Divided into—superior & inferior. Divided into—superior & inferior. Inf.---ant., middle & post. Inf.---ant., middle & post. Middle—contains the pericardium. Middle—contains the pericardium. SUPERIOR SUPERIOR Contents: tra, oeso, muscles, arteries, veins, nerves,thymus, thoracic duct, lymph nodes. Contents: tra, oeso, muscles, arteries, veins, nerves,thymus, thoracic duct, lymph nodes. Clinical: mediastinitis,site of neoplasms,dead space. Clinical: mediastinitis,site of neoplasms,dead space.

67. ANTERIOR MEDIASTINUM In front of pericardium. In front of pericardium. Is cont. with the pretracheal space of the neck. Is cont. with the pretracheal space of the neck. Contents: ligaments, LN, internal thoracic art. Branches,thymus & areolar tissue. Contents: ligaments, LN, internal thoracic art. Branches,thymus & areolar tissue.

69. MIDDLE mediastinum Contains heart,great arteries & veins, nerves, LN & bronchi. POSTERIOR MEDIASTINUM CONTENTS: oeso, DTA, veins, nerves, LN & lymphatics.

71. CLINICAL Sup. & post. mediastinal infections can spread along each other,s territory. Mediastinal syndrome.—SVC, TRACHEA, OESOPHAGUS, LRLN, PHRENIC NERVE,INTERCOSTAL NEURALGIA. Cause: carcinoma, aneurysm, hodgkins.

72. TRACHEA ► Windpipe—organ of respiration ► Lower part neck, in the superior mediastinum ► Divides into R & L bronchi ► Is 4-6 inches long. ► Dia.—2 & 1.5 in M & F. ► Lumen is 12mm. ► Starts from the lower border of cricoid cartilage.

73. Structure:--fibroelastic, C-shaped rings 16 20 in no. Structure:--fibroelastic, C-shaped rings 16 20 in no. Post. It is closed by fibroelastic membrane & contains the trachealis muscle. Post. It is closed by fibroelastic membrane & contains the trachealis muscle. Blood supply—inf. Thyroid art. Blood supply—inf. Thyroid art. Vein: L brachiocephalic vein Vein: L brachiocephalic vein Lymph: pre & paratracheal LN. Lymph: pre & paratracheal LN.

76. Nerve suply---parasympathetic & sympathetic Nerve suply---parasympathetic & sympathetic APPLIED APPLIED Tranlucency Tranlucency Palpation Palpation Tracheal tug Tracheal tug Tracheostomy Tracheostomy Swallowing Swallowing Mucus barrier Mucus barrier Husky voice Husky voice

77. Thoracic duct Largest lymphatic vessel Largest lymphatic vessel Starts from the upper part of the abdomen to the lower part of neck. Starts from the upper part of the abdomen to the lower part of neck. Crosses from the R to the L. Crosses from the R to the L. Goes through the post. & sup. Mediastinum. Goes through the post. & sup. Mediastinum. 18 inch. Long. 18 inch. Long. Has valves so looks beaded. Has valves so looks beaded.

78. Cysterna chyli cont. up as the TD. Cysterna chyli cont. up as the TD. Enters though the aortic opening. Enters though the aortic opening. At level of 7 th C Vert., it arches laterally. At level of 7 th C Vert., it arches laterally. Ends by opening into the bifurcation of the L brachiocephalic vein into L subclavion vein & the L IJV. Ends by opening into the bifurcation of the L brachiocephalic vein into L subclavion vein & the L IJV. RELATION: in theaortic opening, post., sup. Mediastinum & in the neck. RELATION: in theaortic opening, post., sup. Mediastinum & in the neck.

81. TRIBUTARIES Receives lymph from below the diaphragm Receives lymph from below the diaphragm & also from the L upper half of the body. & also from the L upper half of the body. Collects lymph from the L jugular trunk, L subclavion trunk, L Mediastinal trunk. Collects lymph from the L jugular trunk, L subclavion trunk, L Mediastinal trunk.

83. Thank you