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LUNGS AND PLEURAE

GROSS
KARLOS R. ALETA, M.D.

-reach the Midclavicular line at 8th costal


cartilage
The Pleura
-10th rib at Midaxillary line
•Serous layer of mesothelium that invest & -12th rib at the scapular line
enclose each lung
•Visceral pleura – lines the lung itself
•Parietal pleura – lines the chest wall Inferior Margin of the lungs reach:
•Pleural cavity – contains a layer of serous -Midclavicular line at 6th rib
pleural fluid for lubrication (100mL produced -Midaxillary line at 8th rib
and absorbed daily ) -Scapular line at 10th rib

THE PARIETAL PLEURA


•Costal pleura – in the ribs
•Mediastinal pleura
•Diaphragmatic pleura – on top of the diaphragm
•Cervical pleura/suprapleural membrane
Left:
• Pleural reflection moves laterally from
the midline then inferiorly up to the 6th Clinical Importance:
costal cartilage Posteriorly the pleural may go beyond the costal
• Left lung is more deeply indented by the margin – Prone to injury during abdominal
cardiac notch surgery
Right: During kidney surgery, injury to the pleura may
• Pleural reflection continues inferiorly occur and cause air to enter into the thoracic or
from 4th to 6th costal cartilage pleural cavity
• Lung parallels pleural reflection closely
Surgical pleurae/Pleural Cupola – covering in
Pleural reflection pass: the apical area
-lateral at 6th rib ‐ Right and left

Gross Anatomy Lungs and Pleurae 1


LUNGS AND PLEURAE
GROSS
KARLOS R. ALETA, M.D.

‐ Most superior part is below the 1st rib but •LDH 0.6
never above the neck of the 1st rib •Unilateral or Bilateral
‐ Extends in the superior thoracic aperture
to go to the neck
‐ Dome shaped groove Transudate Exudate
‐ Because of position,if there is injury to (high pressure)
neck (laceration, gunshot wound, ice Common causes: Common causes:
pick), the pleural may also be injured and •Congestive heart •Infection
also the underlying lung. failure •Malignancy
•Renal insufficiency •Treatment:
Pleura reflection ends 2 finger breaths above the •Cirrhosis •Drainage
most inferior costal margin Treat the primary •Antibiotics (for
cause- Correct fluid parapneumonic effusions
Pleural Recesses balance and empyemas)
•On full inspiration – lungs fill up cavities •Pleurodesis (for
•Quiet respiration – 3 parts not occupied malignant effusions)
•Area of acute P R – “parietal on parietal pleura
reflection”
Thoracentesis
-R&L Costodiaphragmatic recesses • Draining the fluid in the thorax w/ a
-Costomediastinal Recess needle
• Patient’s back to Physician w/ elbows
Disorders of the Pleura forward & raised 90°
• Allows to move scapula tip laterally –
Hydrothorax away from field of puncture
-fluid accumulation in the thorax or pleural • Insert needle on appropriate ICS~top of
cavity rib (decrease chances of hitting the VAN
-can be anything ie. blood, chyle, pus bundle)
-as fluid increases the lungs will be more
collapsed and near the hilum Pneumothorax
-if you want to breath you can’t utilize the whole -normal parenchyma balloons
parenchyma because its squished • Usually due to rupture of subpleural cyst
-the fluid prevents expansion or bulla
• Air in the pleural space
Classic signs: • Primary: it just happened
•Dullness on percussion • Secondary: pt has an already existing
•Decreased breath sounds lung problem
•Mediastinal displacement • Pt is usually dyspneic, breath sounds
- (organs are pushed to the other side) absent or decreased
•Transudate vs Exudate • Other PE…??? Tachypnia, eyes are
•Total protein 0.5 enlarged, engorged neck vein

Gross Anatomy Lungs and Pleurae 2


LUNGS AND PLEURAE
GROSS
KARLOS R. ALETA, M.D.

• Diagnosis is confirmed with chest xray


• If persistent beyond 3 to 4 weeks
•Treatment: • Ligation of Thoracic Duct
–Drainage with a chest tube • Talc Pleurodesis
Pleuroperitoneal shunt – direct chyle to
For persistent air leaks or recurrences: the peritoneum to the abdomen to be
–Video Assisted Thoracoscopic Surgery (VATS) absorbed
–Thoracotomy
The Lungs
–Oversewing of bleb
–Pleural scarification/abrasion • Essential organs of respiration
• Normally light, soft & spongy
Hemothorax • Left & Right separated fr @ other by
• Accumulation of blood in the thorax mediastinum
• Usually seen in chest trauma, blunt or • Attached: heart & trachea by the “root of the
penetrating lung”
• Anticoagulant therapy Inferior Pulmonary ligament
• Treatment
• Chest tube drainage -cardiopulmonary machine - lung surgery
• For trauma cases: Thoracotomy for -in newborns: light and spongy
control of hemorrhage (>200ml/hr -mediastinum in the middle - no communication
drainage) bet. R&L lungs
• Blood can rise and fill upthe whole lungs Trachea connects to the lung itself
until it collapse.
Empyema Thoracis - pus Surface Anatomy
• Develops from untreated or inadequately • Cervical pleurae & apices
treated parapneumonic effusions • Pass through superior thoracic aperture
• Post op patients (lung resections or pleural into the supraclavicular fossa
procedures) • Anterior borders of lungs
*pus has its own lining • Adjacent to anterior lines of reflection of
• Empyemectomy - removing the pus as a the parietal pleura up to level of 4th costal
whole cartilages
• Decortication – prolonged cases; pus has
hardened; stripping the lining out of the lung Fissures
in order for the lungs to expand again Oblique
- extends from spinous process of T2 vertebra to
Chylothorax 6th costal cartilage
• Accumulation of lymph in the pleural cavity - Coincides w/3 vertebral border of scapula when
• Tumor arm is elevated
• Injury to Thoracic Duct (the aqueduct of the Horizontal
lymph) - is at the 4th rib & costal cartilage anteriorly

Gross Anatomy Lungs and Pleurae 3


LUNGS AND PLEURAE
GROSS
KARLOS R. ALETA, M.D.

•Superior: cardica •Upper


notch,lingula •Middle: wedge-
•Inferior shaped
- 2 lobes •Lower
Lingula- homologue of - 3 lobes
the middle lobe of the middle lobe - most
right anterior

Surfaces
1.) Costal - curvature of the ribs
2.) Medial
a. Mediastinal
-contains root/hilum of lung
-Cardiac impression
b. Vertebral
3.) Diaphragmatic -“base”

Borders
1.)Anterior - Overlaps pericardium
2.)Posterior - Thick & rounded
3.)nferior - Thin & sharp
- Costodiaphragmatic recess

Trachea and Bronchi


•Main bronchi (1°)
@ divides into lobar bronchi

(2°)segmental bronchi (3°)


•Right – wider, shorter
─ more vertical > left
Lobes
Foreign Bodies
Left Right Mucus membrane- last defense for foreign
objects

Trachea - Midline tubular structure w/ 22 rings


Carina -divides R&L
Pediatric pt - swallowed objects usually found in
the right bronchi
Mucus membrane

Gross Anatomy Lungs and Pleurae 4


LUNGS AND PLEURAE
GROSS
KARLOS R. ALETA, M.D.

Lower Lower
Brochopulmonary Segment • superior basal • superior basal
•Pyramidal-shaped lung segment
•Largest subdivision of a lobe
• medial basal • anterior basal
•Supplied independently • anterior basal • lateral basal
-Segmental bronchus
-Supplied by 3° branch of pulmonary • lateral basal • posterior basal
artery
• posterior basal
-drained by intersegmental parts of
pulmonary vein Apico-posterior : merged as one segment
•Named acc to segmental bronchus supplying it Superior-inf: lingular segment
•Surgically resectable

Right (10 segments) Left (8 segments)


Upper Upper
• apical • apico-posterior

• posterior • anterior
• anterior • superior
Middle
• lateral • inferior

• medial

Gross Anatomy Lungs and Pleurae 5


GROSS
LUNGS AND PLEURAE
KARLOS R. ALETA, M.D.

Disorders of the Lungs •Primary mode of treatment is medical


(antibiotics)
Lung Cancer
• Most common malignant tumor affecting -Can involve a segment or a lot of segments
males & females Hemoptysis =coughing of blood
• Smoking
• What do we know? Pathophysiology:
 Most cases are caused by the •Impaired airway defense & ↓ Immunologic
environment, primarily from mechanisms ~permit colonization & infection
tobacco exposure •Bacteria & inflammatory cells elaborate
 Absent smoking, lung cancer proteolytic & oxidative molecules
would be uncommon •Progressively destroy muscular & elastic
 Genes have a role in components ~ fibrous tissue
susceptibility, but which ones and - Chronic airway inflammation
the extent is unclear - Airway w/ thick purulent secretions
Causes: •↑ vascularity, hypertrophied vessels
-Smoking
-Radon gas Clinical Presentation:
- Asbestos •Daily persistent cough + purulent sputum
-Recurring lung inflammation production ~correlate w/ extent
-Lung scarring secondary to tuberculosis •↑ symptoms & respiratory impairment ~ ↑
-Family history airway obstruction
-Exposure to other carcinogens such as •Hemoptysis – chronically inflamed friable
bis(chloromethyl)ether, polycyclic aromatic airway mucosa
hydrocarbons, chromium, nickel and organic -Massive ~ erosion of hypertrophied
arsenic compounds bronchial arteries =fatal

Goal of Treatment: Diagnostics:


–Identify tumor, get tissue diagnosis •Chest CT– x-section bronchial architecture
–Determine the stage of the disease •CXR – lung hyperinflation, bronchiectatic
–Surgery cysts,dilated thich-walled bronchi from hila
–Chemotherapy •Sputum culture
–Radiation Therapy •Spirometry – severity of airway obstruction

Bronchiectasis Management:
•Persistent abnormal dilatation of the bronchi •Optimize secretion clearance
generally at the subsegmental level •Use of bronchodilators
•Localized or diffuse – medium-sized airways •Correct reversible underlying causes
•Congenital or acquired •Chest physiotherapy
•Chronic cough with purulent sputum •Acute exacerbations ~ broad-spectrum antiBx
•50% present with hemoptysis •Surgical resection – refractory to Med tx

Gross Anatomy Lungs and Pleurae 6


GROSS
LUNGS AND PLEURAE
KARLOS R. ALETA, M.D.

•Preserve as much lung tissue


Physiotherapy - promote drainage of sputum

Endobronchial tumors can occur in any part of


the bronchial tree
-Endoscopy

-Bulky tumors- can cause obstruction


--mechanical resection + laser if needed
--tracheal resection: resect then connect

_END

Gross Anatomy Lungs and Pleurae 7