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MD3001 Respiratory > Diaphragm > Flashcards

Diaphragm Flashcards

1
Q

What is the anterior attachment of the diaphragm?

A
  • xiphisternum

- costal cartilages of ribs 7-10

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2
Q

Which hemidiaphragm is higher and why?

A
  • the right hemidiaphragm is higher than the left due to the position of the liver in the upper right quadrant
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3
Q

What are the attachments of the right and left cruras of the diaphragm?

A
  • right crus: bodies and intervertebral disks L1-3

- left crus: bodies and intervertebral discs L1-2

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4
Q

What is found between the cruras of the diaphragm?

A

median arcuate ligament

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5
Q

What are the attachments of the medial and lateral arcuate ligament?

A
  • medial arcuate ligament: L1

- lateral arcuate ligament: rib 12

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6
Q

What are the 3 openings in the diaphragm?

A
  • T8: caval opening for IVC and right phrenic nerve
  • T10: oesophagus, anterior and posterior vagal trunks
  • T12: aortic hiatus for thoracic duct and azygos
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7
Q

What are the relations of the IVC, oesophagus and aorta to the diaphragm?

A
  • IVC pierces tendinous part of diaphragm
  • oesophagus passes through muscular slip in diaphragm
  • aorta lies behind the diaphragm with left and right cruras at either side
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8
Q

What is the risk with the oesophageal opening in the diaphragm?

A

it’s entry into the diaphragm does not forma true sphincter and risks the possibility of reflux of gastric acid from the stomach which can cause heartburn

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9
Q

What nerves innervate the diaphragm?

A
  • phrenic nerve C3,4,5
  • motor and sensory to central portion (as well as fibrous and parietal pericardium and mediastinal pleura)
  • intercostal and subcostal nerves
  • peripheral innervation
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10
Q

Describe how the phrenic nerve travels to the diaphragm

A
  • phrenic nerve travels between venous and arterial planes in superior mediastinum
  • descends anterior to the roots of the lungs on either side
  • right phrenic nerve passes through diaphragm with IVC
  • left phrenic nerve pierces diaphragm but does not pass through it
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11
Q

Describe the vascular supply of the diaphragm

A
  • internal thoracic artery (from 2nd part of subclavian) and gives off
  • pericardiophrenic artery
  • musculophrenic arteries
  • 2 inferior phrenic arteries (from abdominal aorta)
  • superior phrenic arteries (from thoracic aorta)
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12
Q

Where does referred pain from the diaphragm go to?

A

C4 dermatome

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13
Q

Describe the diaphragm in respiration

A
  • inspiration: diaphragm flattens increasing volume in thoracic cavity
  • expiration: diaphragm is raised reducing volume in thoracic cavity
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14
Q

Describe Boyle’s Law

A
  • pressure exerted by gas is inversely proportional to the volume it occupies
  • increasing volume in thoracic cavity during inspiration reduces the pressure relative to the atmospheric pressure so air flows into the lungs
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15
Q

Describe what happens when there is damage to the right phrenic nerve and what that would look like in a chest X-ray

A
  • as volume of the thoracic cavity increases during inspiration, pressure in the abdominal cavity increases causing the right hemidiaphragm to rise (rather than flatten)
  • this elevation is visible on an X-ray
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16
Q

What can cause damage to the phrenic nerve?

A
  • cardiac surgery

- invasion of the phrenic nerve by a lung tumour

17
Q

What do the intercostal muscles do during inspiration?

A
  • external intercostal muscle fibres contract and elevate the ribs and the sternum
  • increases the antero-posterior and lateral diameter of the thoracic cavity
18
Q

What muscles are involved in forced respiration?

A

Inspiration:

  • diaphragm (descends up to 10cm)
  • external intercostal muscles
  • accessory muscles of inspiration (trapezius, scalenes, sternocleidomastoid)
  • nasalis (flares nostrils increasing volume of inspired air)

Expiration:

  • diaphragm and external intercostal muscles
  • internal intercostal muscles (to help reduce intra-thoracic volume)
  • muscles of abdo wall (to help increase intra-abdo pressure)
19
Q

When does forced respiration occur?

A
  • exercise

- ‘normal breathing pattern’ in those with COPD/lung disease

20
Q

What is the function of the pleura?

A
  • reduce friction to allow movement of lungs

- intrapleural pressure: negative relative to atmospheric pressure to prevent collapse of the lungs

21
Q

Describe the surface markings of the parietal pleura

A
  • the apex on both sides are 2-3cm superior to the middle of the clavicle
  • both descends down the midline of the chest until 4th CC where it deviates slightly laterally on the left pleura to accomodate the heart
  • right sits midline at 6 CC
  • left sits lateral to the sternum at 6 CC
  • mid-clavicular line sits 8CC
  • from mid-axillary line sits at the 10th rib
  • both sits at lateral border of erector spinae at T12
22
Q

Describe the surface marking of the lungs and the areas of potential space

A
  • surface marking is the same as the pleura but the lungs sit 2 ribs higher to allow expansion
  • potential space in the costodiaphragmatic recess where 2 layers of parietal pleura oppose each other
23
Q

Describe the surface markings of the lung lobe fissures

A

Right lung:

  • horizontal fissure starts at 4 CC anteriorly and ends meeting the oblique fissure
  • oblique fissure can be drawn from T4 vertebrae posteriorly to 6th rib anteriorly
24
Q

Describe where you would put the stethoscope to auscultate the different lobes of the lungs

A
  • 2nd intercostal space anteriorly/superiorly for superior lobes
  • 4th intercostal space on the right for middle lobe (can’t be auscultated posteriorly)
  • 6th intercostal space for lower lobes
  • 7th intercostal space for inferior lobes
25
Q

Pneumothorax

A

air in the thorax between the visceral and parietal layers of pleura causing compression of the lung tissue

26
Q

Haemothorax

A

blood between visceral and parietal layers of pleura

27
Q

Chylothorax

A

lymph between visceral and parietal layers of pleura

28
Q

What are the clinical signs and symptoms of a pneumothorax?

A
  • dyspnoea

- pleuritic chest pain

29
Q

What are the risk factors for a pneumothorax?

A
  • tall
  • male
  • smoker
  • underlying lung disease/COPD/asthma
30
Q

What happens during a tension pneumothorax?

A
  • medical emergency
  • air is trapped between layers of pleura
  • valve like effect causes air to enter the pleural space and not leave
  • increasingly positive intrapleural pressure
  • trachea and mediastinum shifted away from side of pneumothorax
  • venous return to heart is impaired causing hypotension and cardiac arrest
31
Q

What would you do in a tension pneumothorax?

A
  • decompress

- insert a cannula on the side of the pneumothorax at the 2nd intercostal space mid-clavicular line

32
Q

What are the indications for a chest drain?

A
  • large pneumothorax
  • tension pneumothorax
  • traumatic haemothorax
  • large pleural effusion
  • aims to enable removal of fluid/air from intrapleural space
33
Q

What is the ‘safe’ triangle and what are its borders?

A
  • the site where you can insert a chest drain

Borders:

  • base of axilla
  • lateral edge of latissimus dorsi
  • 5th intercostal space
  • lateral edge of pectoralis major
34
Q

What are possible complications of a chest drain (even in the safe triangle)?

A
  • false passage: instead of the tube sitting in the intrapleural space it just tunnels under the subcutaneous tissue
  • damage to long thoracic nerve
  • haemothorax due to damage to intercostal arteries
  • liver/spleen injury

MD3001 Respiratory (38 decks)

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