Lung Presentation - Steve

Question 1

Where are the lines of reflection of the parietal pleura?

Answer 1

a. Vertebral – costal pleura becomes continuous with mediastinal pleura posteriorly.
b. Costal – costal pleura becomes continuous with diaphragmatic pleura inferiorly.
c. Sternal – costal pleura becomes continuous with mediastinal pleura anteriorly.

Question 2

The extention of the cervical pleura into the root of the neck is clinically relevant as it may be punctured due to wounds in this region with a resulting __________.

Answer 2

Pneumothorax

Question 3

A 25 y/o male presents to the ED with a ice pick stab wound to the left thoracic wall at the level of the 9th intercostal space near the MAL. The patient displays dyspnea, cyanosis, and lack of breath sounds on the left. The knife most likely damaged what structure?

Answer 3

Costodiaphragmatic recess

Question 4

What is the innervation of the pleura?

Answer 4

Phrenic nerves and intercostal nerves

Question 5

What is inflammation of the pluera called?

Answer 5

Pleuritis, or pleurisy

Question 6

What is shown in in this image?

Answer 6

Pneumothorax

Question 7

Tall, lanky men (typically) are at risk for what lung condition?

Answer 7

Primary, or spontaneous, pneumothorax

Question 8

If the pleura membranes become inflamed due to disease (pleuritis or pleurisy), they become rough and no longer slide easily over one another. Why is this so painful? Where is pain referred to? Associated cord levels?

Answer 8

Pleuritis can be very painful because the parietal pleura receives extensive sensory innervation from intercostal and phrenic nerves. Thus, pain is referred to the area of the thoracic wall or to the point of the shoulder via the phrenic nerves (C3,4,5). The visceral pleura sensory nerves travel with autonomic fibers of the bronchial vessels.

Question 9

The right sternal reflection passes inferiorly in the medial plane to the level of the 6th costal cartilage; the left sternal reflection passes inferiorly in medial plane to the level of the 4th costal cartilage and then turns laterally and inferiorly to the level of the 6th costal cartilage.

Why is this clinically important?

Answer 9

This creates a notch allowing a small part of the pericardium to be in direct contact with the anterior thoracic wall (bare area of the heart; important for pericardiocentesis).

Question 10

How many surfaces and borders do the lungs have? Name them.

Answer 10

3 borders- anterior, inferior, posterior (rounded)

3 surfaces - costal, mediastinal, diaphragmatic

Question 11

What separates the lobes of the right lung?

Answer 11

Superior and middle are separated by a horizontal fissure.

Middle and inferior lobes are separated by the oblique fissure

Question 12

What separates the lobes of the left lung?

Answer 12

Superior and inferior lobes separated by the oblique fissure

Question 13

What does the plueral cavity contain?

Answer 13

Contains a minimal amount of lubricating serous fluid; between parietal and visceral pleura. NOTHING else in IN the pleural cavity.

Question 14

What are the pleural recesses?

Answer 14

a. Areas of pleural cavity which the lungs do not completely occupy during quiet respiration; two layers of parietal pleura come into contact with each other.
b. Costomediastinal – where mediastinal pleura reflects to become costal pleura anteriorly.
c. Costodiaphragmatic – where costal pleura reflects to become the diaphragmatic pleura (inferiorly, around periphery of diaphragm).

Question 15

a.The costodiaphragmatic recess can inadvertently be damaged during procedures or injuries in the abdomen since it…

Answer 15

reflects at TV12 posteriorly (like renal biopsies).

Question 16

Describe the bronchopulmonary segments

Answer 16

1. Smallest functional unit of the lung.
2. Area supplied by 1 tertiary bronchus and associated branch of pulmonary artery.
3. Separated from adjacent segments by connective tissue septa.
4. Pulmonary veins run between bronchopulmonary segments (i.e. intersegmentally)

Question 17

What clinical correlations are associated with the bronchopulmonary segments?

What are the surgical treatment options available?

Answer 17

Diseases of the lung (tumors, abscesses) often localize to a bronchopulmonary segment. These segments can be surgically resected without altering function of other segments.

a. Pneumonectomy = surgical removal of one lung
b. Lobectomy = surgical removal of one lobe of the lung
c. Segmentectomy = surgical removal of a bronchopulmonary segment

Question 18

Identify the tagged structures and describe the path of blood flow.

Answer 18

Question 19

Describe the systemic circulation of the lungs.

Answer 19

a. Bronchial arteries
1. Originate from thoracic aorta.
2. Typically two on the left and one on the right; the right often originates from 3rd right posterior intercostal artery.
3. Courses with the bronchial tree.
4. Supply trachea and bronchii.
b. Bronchial veins – course with bronchial arteries; terminate in azygos veins.

Question 20

What are the lymph nodes we need to be aware of? Briefly describe each.

Answer 20

1. Pulmonary nodes – within substance of lung; along bronchial tree.
2. Bronchopulmonary nodes – at hilum of lung.
3. Tracheobronchial nodes – at tracheal bifuration.
4. Superficial (subpleural plexus) lymphatic system
   a. Drains visceral pleura and most of lung parenchyma.
   b. Drain to bronchopulmonary nodes → superior and inferior tracheobronchial nodes → bronchomediastinal trunk.
   c. The bronchomediastinal trunk drains to the thoracic duct on the left and to the right lymphatic duct on the right.
5. Deep pulmonary plexus
   a. Drains larger bronchioles and bronchi.
   b. Drain to pulmonary nodes → bronchopulmonary nodes → tracheobronchial nodes → bronchomediastinal trunk
6. Note: lymph from the left inferior lobe drains to right tracheobronchial nodes.
7. Note: lymphatic drainage of the parietal pleura is to the thoracic wall (mainly intercostal, but also parasternal, diaphragmatic, axillary lymph nodes).

Question 21

Where is the auscultory triangle?

Answer 21

triangle-at TV8 (trapezius, lattissimus and rhomboids)

Question 22

Where are the auscultory spots on the anterior anatomy?

Answer 22

Question 23

Where are the posterior auscultory points?

Answer 23

Question 24

A 7 y/o male with a history of asthma attacks presents with difficulty breathing and obvious wheezing sounds with each breath. What is the most likely mechanism mediating this patient’s symptoms?

Answer 24

Increased parasympathetic stimulation to tracheobronchial tree

Question 25

Hemothorax

Answer 25

•blood in thoracic cavity

Question 26

Pneumothorax

Answer 26

•air in thoracic cavity

Question 27

Empyema (pyothorax)

Answer 27

•pus in thoracic cavity

Question 28

Chylothorax

Answer 28

•chyle(lymphatic fluid) in thoracic cavity

Question 29

Describe pancoast syndrome

Answer 29

Pancoast (tumor) syndrome results from a malignant neoplasm of the superior lobe of the lung with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic ganglion.

Question 30

What are symptoms of the pancoast tumor/syndrome?

Answer 30

1) Severe pain in the shoulder region radiating toward the axilla and scapula
2) Pain along the ulnar aspect of the muscles of the hand

3) Atrophy of hand and arm muscles
4) Horner’s syndrome = “ptosis, miosis and anhidrosis”

Question 31

Describe Horner’s Syndrome

Answer 31

Horner’s syndrome = “ptosis, miosis and anhidrosis”

Question 32

Where do the ribs usually seperate?

Answer 32

Costochondral joints

Question 33

At what levels are the constrictions to the esophagus seen?

Answer 33

CV6 (origin)

TV4-5 (aortobronchial constriction)

TV10 (diaphragmatic constriction)

Question 34

What are the levels of the splanchnic nerves?

Answer 34

Greater (TV5-9)

Lesser (TV 10,11)

Least ( TV 12)

Question 35

Why are things more likely to go into the right main bronchi?

Answer 35

It is shorter and larger than the left.

Question 36

What is Virchow’s node?

Answer 36

abnormally enlarged lymph node(s) in the left supraclavicular fossa . Supplied by lymph vessels in the breast, thorax and abdominal cavity.

(Virchow’s node is also sometimes called “the seat of the devil” given its ominous association with malignant disease.)