Week 7 Flashcards
Understand the role of a medical history in making a clinical diagnosis
-Form a differential diagnosis and put health in
context
-Identify risk factors for conditions
- Red flags
-Direct further clinical examination
-Direct investigation and management
-Develop a rapport between patient and health care worker
To understand how different body systems inter-relate
Couple of questions to each remaining system as a quick screening tool
Causes of non-central chest pain?
Pleural:
- Pneumonia/bronchiectasis/TB
- Lung tumours/metastases/mesothelioma
- PE
- Pneumothorax
Chest wall
- Muscular / rib injury
- Costochondritis
- Lung tumour / bony metastases/ mesothelioma
- Shingles (herpes zoster)
Respiratory causes of dyspnoea?
– Airways e.g. asthma, COPD, bronchiectasis, cystic fibrosis, laryngeal tumour, foreign body, lung tumour
– Parenchyma e.g. pneumonia, pulmonary fibrosis, sarcoidosis, TB
– Pulmonary circulation e.g. PE
– Pleural e.g. neumothorax , pleural effusion
– Chest wall e.g. kyphoscoliosis, ankylosing spondylitis
– Neuromuscular e.g. myasthenia gravis, Guillain-Barre syndrome
Respiratory causes of dyspnoea?
– Airways e.g. asthma, COPD, bronchiectasis, cystic fibrosis, laryngeal tumour, foreign body, lung tumour
– Parenchyma e.g. pneumonia, pulmonary fibrosis, sarcoidosis, TB
– Pulmonary circulation e.g. PE
– Pleural e.g. neumothorax , pleural effusion
– Chest wall e.g. kyphoscoliosis, ankylosing spondylitis
– Neuromuscular e.g. myasthenia gravis, Guillain-Barre syndrome
Cardiovascular causes for dyspnea?
Cardiac failure, associated with angina/MI
Non cardio-respiratory causes f dyspnea?
Anaemia, obesity, hyperventilation, anxiety, metabolic acidosis
Non cardio-respiratory causes f dyspnea?
Anaemia, obesity, hyperventilation, anxiety, metabolic acidosis
Different types of cough?
Acute and chronic
Acute:
– Viral or bacterial infection / pneumonia / inhalation of foreign
body/ irritants
Chronic cough
– Common - gastro-oesophageal reflux / asthma/ COPD / smoking / post-nasal drip / occupational or other irritants /medication (ACEI)
– Less common – lung tumour / bronchiectasis / interstitial lung disease
Red flags for cough?
– Haemoptysis, breathlessness, weight loss, chest pain, smoker
Red flags for cough?
– Haemoptysis, breathlessness, weight loss, chest pain, smoker
Identify the common causes for the following characteristics of cough:
- Productive
- Persistent ‘moist’ cough worst in morning
- Associated with wheeze
- Pain
- Harsh/barking
- Chronic, dry cough
- Persistent with haemoptysis
- ‘Bovine’ cough (non-explosive cough)
Productive - Infection, Bronchiectasis
Persistent ‘moist’ cough worst in morning-COPD
Associated with wheeze-Asthma / COPD,
Painful-Tracheitis
Harsh/ barking-Laryngitis/ laryngeal tumour
Chronic, dry cough-Interstitial lung disease
Persistent with haemoptysis-Bronchial carcinoma
‘Bovine’ cough (non-explosive cough)-Left recurrent laryngeal nerve invasion, (secondary to malignancy), Neuromuscular disorders
Name the appearance and cause for the following types of sputum:
- Serous
- Mucoid
- Purulent
- Rusty
- Serous. Clear, watery, frothy, pink. Cause = Acute pulmonary oedema
- Mucoid. Clear, grey, white, viscid. Cause = COPD/asthma
- Purulent. Yellow, green, brown/ Cause= Infection
- Rusty. Rusty red. Cause= Pneumococcal pneumonia
6 cause of haemoptysis
Malignant, infective, vascular, cardiac, vasculitis
Why ensure accurate mediation history? 6
- Improves patient safety
- Reduces medication errors / near misses
- Reduces missed doses in hospital
- Reduces delays to treatment
- Savings to NHS from prevented errors
- Improves therapeutic outcomes
What are the issues with concordance?
Intentional non-concordance: Definite decision to not take medicines
Unintentional non-concordance. For example due to:
1. Physical dexterity
2. Reduced vision
3. Cognitive impairment
4. Poor understand
6 different types/forms of inhaler
Mdi= Metered dose inhaler Accuhaler Autohaler Easibreathe Handihaler Via spacer/aerochamber
What are the blue and brown inhaler?
Blue= "reliever" e.g. salbutamol (beta-agonist) Brown = "preventer" e.g. Beclomethasone (steroid)
Define Palliative Care
An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness
Through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems (physical, psychosocial and spiritual)
Discuss the principles of delivering good end of life care
- Open lines of communication
- Anticipating care needs and encouraging discussion
- Effective multidisciplinary team input
- Symptom control - physical and psycho-spiritual (=exacerbates physical symptoms)
- Preparing for death- patient and family
- Providing support for relatives both before and after death
What is advance and anticipatory planning?
Identify areas for discussion during advance and
anticipatory care planning
An ongoing process of discussion between the patient, those close to them and their care providers focusing on their wishes and preferences for their future
Discussion areas:
- Wises/preferences/fears about care
- Emergency preferences (DNR?)
- Preferred place of care
How are the wishes of a patient in advance care decisions formalized?
Formalising wishes:
- Advance statement:
- Advance decision
- Power of attorney
5 priorities of care for dying person
- The possibility that a person may die within the next few days/hours is recognized and communicated clearly
- Sensitive communication takes place between staff and patient/family
- Involvement of patient/family when making decisions about treatment/care
- The needs of families are actively explored, respected and met (if possible)
- Individual plan of care is agreed, co-ordinated and delivered with compassion
Aims of palliative care
- Whole person approach
- Focus on quality of life, including good symptom control
- Care encompassing the person with the life-threatening illness and those that matter to them
In formalizing the patients wishes, what are the features of an advance statement?
- A statement that sets down your preferences, wishes, beliefs and values regarding your future care.
- Will provide guidance if patient were to lose capacity
- Although decisions not bound by statement.
- Treatment must overall benefit to the patient
In formalizing the patients wishes, what are the features of an advance decision?
A decision you can make now to refuse specific treatments in the future
Used in the case that the patient is unable to express/communicate their decision
May be issues around life sustaining treatment (e.g. DNACPR)
Validity and applicability need to be considered.
How is the validity of the advance care plans assessed?
Applicability? Timing? Capacity of patient at time of planning? Informed decision? Undue influences when plan made? Withdrawn decision
4 pro’s and con’s for advance care plans?
PROS
- Enhances autonomy
- May encourage/improve discussions on end-of-life decisions
- Avoid breaching patient’s personal/religious beliefs
- Death with dignity
CONS
- May not be valid
- May not be applicable
- Attitudes may change with onset of serious illness
- May have been advances in medicine since being made
What is the Gold Standard Framework?
Systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by
generalist frontline care providers
4 principles of care for people in the last days and hours of life
Principle 1: Informative, timely and sensitive communication
Principle 2: Significant decisions about a person’s care are made on the basis of multidisciplinary
discussion
Principle 3: Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed
Principle 4: Consideration is given to the wellbeing of relatives or carers attending the person
What is the basic structure of a respiratory examination?
IIPPAC
Introduction and explanation Inspection: General and Close (hands, face, chest/neck) Palpation Percussion Auscultation Conclusion
What pathological signs should you look out for when performing the general and close inspection in a respiratory examination?
General:
- Nebuliser/inhaler
- Erythema nodosum
Close:
Hands- Flapping tremor, fine termor, tar staining, nail clubbing
Face- Central cyanosis, ruddy complexion due to polycythmaeia, Horner’s syndrome
Neck/chest- Scarring, kyphoscoliosis, SVC obstruction, JVP raised
What are the respiratory causes of clubbing?
Bronchial carcinoma Mesothelioma Chronic suppurative lung disease Pulmonary fibrosis Cystic fibrosis
Horners syndrome:
Caused by?
Clinical features?
Caused by damage to cervical sympathetic nerves
Clinical features:
-Unilateral miosis
-Partial ptosis
-Loss of sweating on same side (ie facial anhidrosis)
What is the cause of fine tremor?
Excessive use of B-agonists
What is the cause of flapping tremor? Name 4 features
Due to severe ventilator failure with CO2 retention
Features:
- Hold hands outstretched
- Wrists cocked-back
- Jerky, flapping tremor
What are the areas inspected on the close inspection of the neck/chest in a respiratory exam?
- Scars – cardiac surgery, thoracotomy, chest drain scars
- Pattern of breathing
- Shape of chest
– Symmetry
– Deformity (kyphoscoliosis / pectus excavatum)
– Increase in A-P diameter (‘barrel shaped’) - Prominent veins on chest wall
– SVC obstruction - JVP
What are the different stages of palpation of the neck and chest?
- Lymph nodes: Patient sat forwards
- Subcutaneious emphysema: Crackling sensation, air in subcutaneous tissues
- Consider trauma/ underlying pneumothorax
- Mediastinal position: Check tracheal position and cardiac apex
- Chest expansion: Anterior/posterior, patient to breeze deeply, thumbs should move apart equally
How do you carry out the percussion section of the respiratory exam?
- Anterior/posterior chest
- Use middle finger/left hand
- Apply firmly to patient’s chest
- Strike it’s middle phalanx with the middle finger of righ hand
- Percuss over intercostal spaces
- Compare left and right
- Listen to note produced
- 7 on back, 6 on front
Name possible causes for the following percussion notes:
- Resonant
- Hyper resonant
- Dull
- Stony/ Very dull
- Resonant: Normal lung
- Hyper resonant: Emphysema/ pneumothorax
- Dull: Collapse/ consolidation/ fibrosis
- Stony/ Very dull: Pleural effusion
What is involved in the auscultation stage of the respiratory exam?
- Use bell or diaphragm of stethoscope
- Ask patient to breathe deeply through mouth
- Listen through full inspiration and full expiration
- Listen for breath sounds and added sounds
What are the breath sounds heard on auscultation?
Normal (vesicular)
- Intensity of sounds relates to airflow
- Diminished vesicular breath sounds (e.g. obesity, pleural effusion, pneumothorax, collapse, hyperinflation in COPD)
Bronchial (high pitched)
-Consolidation with patient bronchial system (e.g. pneumonia, top of pleural effusion, pulmonary fibrosis)
What are the added sounds heard on auscultation?
Crackles (crepitations)
-Caused by e.g. pulmonary oedema, pulmonary fibrosis, bronchial secretions, COPD, pneumonia, lung abcess, TB, bronchiolitis, bronchiectasis
Pleural rub
- Usually associated with pleuritic pain
- Caused by PE, pneumonia, vasculitis
Wheeze
- Continuous oscillation of opposing airway walls
- Musical quality
- Implies airway narrowing
- Louder in expiration
- Caused by Asthma/COPD (if generalized) and lung tumour (if localized)
Silent check in severe airways obstruction
What is fremitus?
Fremitus refers to vibratory tremors that can be felt through the chest by palpation
How are the followed assessed:
- Vocal fremitus?
- Vocal resonance?
- Increased resonance?
- Decreased resonance?
Vocal fremitus: Use palm / ulnar border of hand
Vocal resonance :Use stethoscope
Increased resonance: Consolidation / fibrosis
Decreased resonance: Pleural effusion / collapse
What are the other areas to assess in a respiratory examination?
Ankle oedema
Sputum pot
Obs chart
Peak flow
Spirometry
Outline the key arguments often cited for/against the use of animals in research
Aspects to consider:
- Benefits
- Model
- Sentience
- Value
- Moral agency
- Spiritual/religious potential
- Human achievement
Explain the three principles governing the use of animals in research (from the Home Office policy)
(3 R’s)
Replacement: e.g. alternative technologies
Reduction: e.g. better study design to allow use for fewer animals, better storage of data
Refinement: e.g. improve housing, minimize pain, improve welfare
Outline the regulatory role of the Home Office in animal research
Home Office: “Secretary of Sate weight the likely adverse effects on animals concerned against the benefit likely to accrue as a result of the programme”
Each local arena, animal ethics committee (reviews and monitors all eligible research, using ASPA and Home Office guidelines)
Licenses are granted: Site license, personal license, project license
Informed consent:
What is it?
Four criteria for valid consent?
4 difficulties that can arise in acquiring informed consent
Informed consent = First principle of Nuremberg Code
4 criteria for valid consent:
- Patient must have capacity
- Patient must give consent voluntarily
- Patient must be informed
- Consent must be continuing
Difficulties:
- Participant feeling pressure into agreeing
- The problem of incentives
- Sufficient information
- Vulnerable patients
Identify the different ethical issues raised by the:
- Tuskegee Syphilis trial
- The Guatemalan STD trial
- The case of Henrietta Lacks
Tuskegee Syphilis trial
- “a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks..”
- No informed consent
- Time span extended x80
- Participants given incentives
- No treatment given to treat syphilis or was allowed to be given
The Guatemalan STD trial
- No consent was sought
- Experiments on 5000+ soldiers, prisoners, psychiatric patients, orphans and prostitutes
- Exposed participants to gonorrhea, syphilis or chancroid
The case of Henrietta Lacks
- First immortal human cell line HeLa
- After death her cells were used for research worldwide
- No consent sought
- Profit made from cells hasn’t gone to family
- Justification: Material no longer “hers”, material would have been thrown away, for the common good
Name 3 types of transmission based precautions
Airborne, droplet, contact
Two strategies to measure quality of care?
- The Francis Report is leading to a paradigm shift in clinical care
- Health Improvement Scotland (HIS)
Two strategies to measure quality of care?
- The Francis Report is leading to a paradigm shift in clinical care
- Health Improvement Scotland (HIS)
Hospital acquired infections are one indicator of performance
Two strategies to measure quality of care?
- The Francis Report is leading to a paradigm shift in clinical care
- Health Improvement Scotland (HIS)
Hospital acquired infections are one indicator of performance
How can doctors taken measures to prevent HCAI?
- Recognition of risk factors in patients
- Behaviour and practice
- Hand hygiene
- Dress
- PPE
- Use isolation facilities correctly
How can doctors taken measures to prevent HCAI?
- Recognition of risk factors in patients
- Behaviour and practice
- Hand hygiene
- Dress
- PPE
- Use isolation facilities correctly
What is the chain of infection?
- Infectious agent
- Reservoir
- Portal of Exit
- Mode of transmission
- Portal of entry
- Susceptible host
3 different forms of mode of transmission?
- Direct/Indirect contact via fomites or ingestion e.g. Blood born viruses, diarrhea
- Droplet transmission e.g. N. meningitis, norovirus
- Aerosol (Airborne) transmission e.g. TB, chicken pox, influenza
For which patients should contact precautions be applied?
Name 4 contact precautions in HCAIs
For patients infected/colonized with organisms transmitted by direct or indirect contact e.g. C. difficile, MRSA
Precautions:
- Single room if possible
- Gloves
- Aprons
- Disposable masks/eye protection if at risk of splashes
For which patients should droplet precautions be applied?
Name 2 droplet precautions in HCAIs
For organisms transmitted in droplets (>0.5 microns). These travel only short distances e.g. N. meningitis, mumps, rubella
Precautions:
- Single room if possible
- Wear surgical mark when within touching distance (1 metre) of patient or cough inducing procedure
For which patients should airborne precautions be applied?
Name 5 airborne precautions in HCAIs
Particles <5microns. Can be widely dispersed e.g. TB, chickenpox, measles, FLU
Precautions:
- Wear FFP3 masks for all aerosol generating procedure
- Single room
- Apron
- Gloves
- High efficiency filter mask
In hand decontamination, what are the 2 before and 3 after
Before:
- Touching patien
- Clean/aseptic procedure
After:
- Touching patient
- Touching patient surroundings
- Body fluid exposure risk
Patients with rash and photophobia….
Think measles
After examination of which patients should you use soap and water?
Patient with diarrhea and after removing gloves
What are the two main types of medical devices that could present risk of HCAI?
Invasive medical devices: Maybe long term and short term. All break the skin or mucous membrane barrier
e.g. Central venous catheters (CVC), PVC, urinary catheters
Indwelling prosthetic devices: Usually long term devices which are buried into tissue under the skin e.g. Heart valves, joints, pacing units etc
Two groups of antibiotic resistant organisms?
Gram positive organisms
- MRSA
- VRE (Vancomycin Resistant Enterococcus)
Gram negative enterobacteriaceae
- ESBL producer
- CRE (Carbapenem Resistant Enterobacteriaceae
- Carbapenamase Producing pseudomonas
Explain why evidence based medicine is an important part of modern medicine
As it is the key to clinical effectiveness and decision making. Such as in the…
• Production of evidence through scientific research and review
• Production and dissemination of evidence
based clinical guidelines
• Implementation of evidence based, cost
effective practice through education and change management
• Evaluation of compliance with practice guidance through clinical audit
Define EBM
The conscientious, explicit and judicious use of current best evidence in marking nursing decisions about the care of individual patients
also
The systemic search for, and appraisal of, best evidence in order to make clinical decisions that might require changes in current practice, while taking into account the individual needs of the patient
List the key steps in the process of applying EBM
Use the best evidence in the scientific literature to provide the best care for an individual patient
Summarise the pros and cons of the EBM approach
Cons
- EBM is ‘old hat’
- EBM identifies statistically significant benefits which may be marginal in clinical practice
- EBM has generated a massive, unmanageable volume of evidence and guidelines
- EBM is the mindless application of population studies to the treatment of the individual
- Often no RTC or “gold standard” in the literature to address the clinical question
Pros
- Filters literature so that decisions are made based on “strong evidence”
- EBM should be one part of the process
- Produces expert judgement in a format that clinicians can understand
- Is the info applicable to specific patient
- Clinicians need to understand that there may be no good evidence to support clinical judgement
3 Principles of EBM
- High quality health care rests on objective and clinically relevant information
- There is a hierarchy of evidence where some types are stronger than others
- Scientific data alone is not a sufficient basis for making clinical decisions about individual patients
What questions are answered about drugs by EBM?
The effects of therapy
The utility of diagnostic tests
The prognosis of diseases
The etiology of disorders
How to practice EBM?
- Craft a clinical question (PICO)
- Search the medical literature (medical informatics)
- Find the study that will best answer the question
- Perform a critical appraisal (check for validity and bias)
- Determine how the results will help you care for your patient
- Evaluate the results in your patient or population
What is the pathway involved in air conditioning? What is it’s function?
Function: Moistens, warms, cleans/filters
- Nasal cavity
- Napsopharynx
- Oropharynx
- Larynx
- Trachea
- Main bronchi
- Lobar bronchi
- Segmental bronchi
- Terminal bronchioles
Trachea: Length/width? Structure? Start/end? Muscle present? Difference between RMB/LMB?
Length/width: 10-11cm long, 12mm wide internally
Structure: C-shaped rings of hyaline cartilage supporting a fibro-elastic and muscle air transport tube
Start: C6
End: T4/5 at carina
Muscle present: Trachealis alters tracheal diameter
Difference between RMB/LMB: RMB shorter, wider, more vertical
Major relations to trachea
On RHS: BCT, SVC, right vagus, azygos vein, right brachiocephalic vein, right upper lung lobe
On LHS: LCCA, Descending aorta, left upper lung lobe
Anterior: Thyroid gland, arch of aorta
What structures lies in the groove between the trachea and the oesophagus?
The left recurrent laryngeal nerve
Trachea neurovascular supply: Arteries? Veins? Lymph? Nerves?
Arteries: Inferior thyroid and bronchial
Vein: Inferior thyroid
Lymph: Pre and para tracheal
Nerves: Vagi, recurrent laryngeal, sympathetic trunks
Each segmental bronchus passes to a…….
broncho-pulmonary segment
Each lobar bronchi supplies _ lung lobe
1
What are the names of the bronchopulmonary segments of the right lung? (10)
Upper lobe: Apical, anterior, posterior
Middle lobe: Medial, lateral
Lower lobe: Apical, anterior, lateral, posterior, medial
What are the names of the bronchopulmonary segments of the left lung? (10)
Upper lobe: Apical, anterior, posterior
Middle lobe: Superior, inferior
Lower lobe: Apical, anterior, lateral, posterior, medial
Bronchopulmonary segment:
Orientation on segments?
Separated by?
Orientation: Pyramid with its base on the surface of the lung, apex pointing to the hilum
Separated from each other by connective tissue
Each respiratory bronchioles –> _____ alveolar ducts —> ____ alveoli
Each respiratory bronchioles –> 2-11 alveolar ducts —> 5-6 alveoli
________ _______ are the smallest part of the purely conducting part of the tree. Beyond the terminal bronchioles the passages become increasingly involved in _______ exchange.
So Respiratory bronchioles will have a few ____ coming off their walls and there are no _____ _____ and the epithelium becomes _____. The respiratory bronchioles give rise to several alveolar ____ which branch into _____ sacs and finally alveoli
TERMINAL BRONCHIOLES are the smallest part of the purely conducting part of the tree. Beyond the terminal bronchioles the passages become increasingly involved in GASEOUS exchange.
So Respiratory bronchioles will have a few ALVEOLI coming off their walls and there are no GOBLET CELLS and the epithelium becomes CUBOIDAL. The respiratory bronchioles give rise to several alveolar DUCTS which branch into ALVEOLAR sacs and finally alveoli
The first segmental bronchus to arise posteriorly passes to?
To the apical segments on the lower lobe. Leads to possible complication of pneumonia
Lungs:
3 Borders?
3 Surfaces?
Fissures?
Borders: Anterior, posterior, inferior
Surfaces: Costal, diaphragmatic, mediastinal
Fissures: Oblique (spine of T4 to 6th rib), horizontal (rib 4 or 5)
Phrenic Nerves pass _____ to the lung roots
Vagus nerves posterior
Phrenic Nerves pass anterior to the lung roots
Vagus nerves posterior
Relations of lungs:
Mediastinum from right?
Mediastinum from left?
Mediastinum from right:
- Phrenic nerve
- Heart in pericardium
- Azygos vein
- Sympathetic truk
- Vagus nerve
- SVC
Mediastinum from left:
- Heart in pericardium
- Pulmonary veins
- Bronchus
- Aorta
- Sympathetic trunk
- Left vagus nerve
- Recurrent laryngeal nerves
- Phrenic nerve
What is the arrangement of the vessels at the lung root/hilum?
Main bronchus is posterior (1L, 2 R)
Pulmonary artery is anterior and superior (1L, 2R)
2 pulmonary veins are anterior and inferior
Additional structures present: Lymphatics, hilar lymph nodes, nerves, bronchial vessels
What is the pulmonary ligament and it’s function?
A fold of pleura
Allows hilar movement during respiration and vessel expansion
At which point do the pulmonary arteries arise from the pulmonary trunk?
Pulmonary arteries arise from the pulmonary trunk just below the sternal angle (T4/5).
Difference in the course of the right and left pulmonary artery?
Right is longer
Right passes anterior to the carina and right main bronchus. Lies posterior to the ascending aorta and SVC
Left is shorter
Left lies anterior to the descending aorta
What vessels supply the tissue of the lung (e.g. walls of the bronchi)?
Bronchial arteries supply the tissue of the lung. They may anastomose with pulmonary arteries in the walls of the bronchioles.
Some blood supplied by bronchial arteries drains into the pulmonary veins.
Bronchial veins drain into the azygos system
Lymphatic drainage of the lungs?
- Deep lymphatic plexus running alongside the arteries and the dividing bronchial tree
- Superficial or sub-pleural plexus of lymphatics
Both converge on Pulmonary nodes –> Bronchopulmonary nodes –> Inferior and superior Tracheobronchial nodes (at bifurcation of the trachea) –> Paratracheal nodes –> R+L Bronchomediastinal lymph trunks
The right usually joins the right lymphatic trunk.
The left usually joins the thoracic duct
Nerve supply to the lungs and pleura?
Lungs:
- Supplied by pulmonary plexuses that lie anterior to the main bronchi
- PS fibres from vagus synapse in the plexuses. Postganglionic fibres are bronchoconstrictor, vasodilator, secretomotor
- Sympathetic synapse in the sympathetic ganglia: Postganglionic fibres are bronchodilator, vasoconstrictor
- Pain fibres travel with sympathetic
Pleura
- Visceral pleura has no general sensory supply
- Parietal pleura has sensory fibres from the intercostal and phrenic nerves
What are the symptoms that can occur by a tumour developing on either side of respiratory system?
vice versa for LHS only
On both sides:
- Tumour may impinge upon the phrenic nerve to cause paralysis of the diaphragm on the affected side
- Tumour may impinge upon the sympathetic trunk and embarrass sympathetic supply to the head, causing Horner’s Syndrome (drooping eyelid, constricted pupil, dry/flushed face on affected side)
LHS only: Tumour may impinge upon the recurrent laryngeal nerve to cause hoarseness of the voice
What are the components of the thoracic wall?
12 pairs of ribs and costal cartilages
Sternum
12 thoracic vertebrae
3 layers of intercostal msucele s
Sternum:
3 parts?
Sternal angle of Louis at which position? Joint type?
Articulates which ribs?
3 parts: Manubrium, body, xiphoid process
Sternal angle of Louis at T4/5 and 2nd CC. A secondary cartilaginous joint (symphysis). (The bony articular surfaces are covered with hyaline cartilage, and a fibrocartilaginous disc connects the articulation bones)
Articulates ribs 1-7
Features of a typical rib?
- Head, neck, tubercle, angle and body/shaft of the rib, joins to the costal cartilage (1y cartilaginous joint with costal cartilage)
- Costal groove on the inner surface and close to the inferior border
- Inferior border sharper than the superior border
- 2 articular demi-facets a the rib head. Articulates with own vertebrae and one above.
- Tubercle has a facet
What 4 features are present on the first rib that aren’t on the other ribs?
- Scalene tubercle for the attachment of scalenus anterior
- Groove (upper surface, anterior to scalene tubercle) for subclavian vein
- Groove for subclavian artery and lower trunk of brachial plexus
- Head of rib 1 articulates only with T1 vertebra, not the one above. The tubercle articulates with the transverse process of T1 = rib 1 lies horizontal
What structures could be affected by cervical ribs and what symptoms may arise?
- Trauma to the subclavian artery: Obstruction and possible thrombo-emboli to the forarm. Leads to ischeamia and pallor of forearm
- Compression of the lower trunk of the brachial plexus: Weakness of small muscles of the hand and sensory disturbance to the medial forearm (C8) and arm (T1)
Typical thoracic vertebrae
- Heart shaped body and circular vertebral canal
- Long overlapping spinous processes
- Body with superior and inferior demifacets for articulation with the heads of the 2 pairs of ribs
- Transverse processes that articulate with the tubercles of the pair of ribs
- Superior and inferior facets that allow some rotation (no flexion)
During osteoporotic fracture (collapse) of the vertebral body and facet joint arthritis, what structure is at risk?
Spinal nerve leading to local and spinal (intercostal) nerve pain
Ribs 2-10 articules with the costal facet joints of which vertebra?
Articulates with:
- Superior costal facet of its own number vertebra
- Inferior costal facet of the vertebra above
FORMS COSTOVERTBERAL JOINT
Costovertebral joint type?
Synovial, supported by capsule and ligament
The tubercle of ribs 1-10 articules with its own….
Transverse process
How do the costotransverse processes of the joints vary?
Costotransverse joints 1 to 7 have curved facets, allowing rotatory movement
Costotransverse joints 8-10 have flat facets, allowing gliding movement
(Key in respiratory movements of the thoracic wall)
What are the anterior articulations of the thoracic wall?
All ribs articulate anteriorly with a CC via primary cartilaginous (hyaline) oint
TRUE RIBS (1-7) Articulate directly with the sternum via synovial joints to allow movment (except CC1 with is 1y cartilaginous, more stable for thoracic inlet)
FALSE RIBS (8-10) Articulate with the costal cartilage above to form the costal margin
FLOATING RIBS 11+12 have no anterior articulation
(As the rib number increases, the obliqueness also increase. Key to respiratory movements)
What structure overly the intercostal spaces anteriorly?
Anterior: Pec maj, serratus anterior, pec minor, breast (opposite ribs 2-6)
Intervertebral neurovascular bundle, components and location?
Made up of: Intercostal vein, artery and nerve (VAN)
Location: Costal groove at the inferior edge of the rib, between internal and innermost intercostal muscle
3 layers of intercostal muscle?
External
Inner
Innermost
Intercostal muscles:
Function?
Nervous supple?
Function: Support the intercostal space and prevent indrawing during inspiration
Nervous supply: Supplied by intercostal nerves T1 to T11
External intercostal:
Fibre direction?
Anteriorly?
Function?
Fibre direction: Pass downwards and medially
Anteriorly: External intercostal membrane
Function: Raise ribs, inspiration
Internal intercostal: Fibre direction? Anteriorly? Posteriorly? Function?
Fibre direction: Pass downward and laterally
Anteriorly: External intercostal
Posteriorly: Internal intercostal memebrane
Function: Aids elastic recoil by moving ribs inferiorly in expiration
What are the 3 parts of innermost intercostal muscles?
- Subcostales
- Innermost intercostal
- Transversus thoracis
What supplies the anterior arterial supply to the intercostal space?
Internal thoracic artery:
- Branch of the first part of the L+R subclavian artery
- Lies along the margins of the sternum
- Terminates as the superior epigastric and musculophrenic arteries
- Supplies medial 1/2 of the breast
Anterior intercostal arteries:
- 2 per space (ICS 1-6)
- 7-10 from the musculophrenic
- 11+12 have no anterior supply
What supplies the posterior arterial supply to the intercostal space?
1st part of the subclavian arterty: Costocervical trunk supplies the 1st two spaces via the supreme intercostal artery
Thoracic aorta:
- 9 pairs of posterior intercostal arteries
- 2 per space in spaces 3-11 (passing with the intercostal nerves and their collateral branches)
- 12th branch is the subcostal artery
Anterior and posterior arteries anastomose in the space
In the incident of coarctation of the aorta anastomoses between which vessels forms a collateral circulation/
Anterior intercostals (from Internal thoracic) and posterior intercostals (from aorta)
What vessels are involved in the venous drainage of the intercostal space?
Anterior intercostal veins: -Venae comitantes of the internal thoracic artery and its anterior intercostal arteries drain.
-Drains to internal thoracic vein
Posterior intercostal veins:
- Venae comitantes of the posterior intercostal arteries
- 1st space drains to the BCV
- 2nd and 3rd veins form superior intercostal vein
- On the right it drains to the arch of the azygos and on the left it drains to the LBCV
- All others drain to the azygos system
What is the lymphatic drainage of the thoracic wall?
Anteriorly:
- Drains to parasternal nodes
- These lie alongside internal thoracic artery and drains into the Bronchomediastinal trunks
Posteriorly:
- Drains to intercostal nodes
- These lie on the heads of ribs and drain to thoracic duct (inf) OR to Bronchomediastinal trunks (sup)
[NOTE Skin, breast and superficial muscles drain to Axillary nodes]
Breast:
Arterial supply?
Lymph drainage?
Arterial supply:
- Mainly from branchs of Axillary artery (sup thoracic, thoraco-acromial + laterial thoracic)
- Also: Internal thoracic, anterior intercostal
Lymph: Axillary nodes mainly, also to internal thoracic
Intercostal nerves:
Arise from…
Position?
Branches?
Arise from spinal nerve in intervertebral foramen.
Position: At inferior border of the rib between the internal and innermost intercostal muscles
Branches:
- Lateral and anterior branches to overlying skin
- Collateral branches that run at the upper border of the rub
T1 spinal nerve, supplies??
The ventral ramus mainly goes to the Brachial Plexus to supply:
- Small muscles of the hand, skin of medial aspect of the arm/forearm.
- Sends a branch to supply the muscles of the 1st intercostal space
The ventral rami of T2-T11 are the intercostal nerves and carry…
Carry:
- Motor fibres to intercostal muscles
- Sensory fibres from skin and parietal pleura
- Sympathetic fibres to body wall structures via WRC (1y/Pre-ganglionic) and GRC (2y/post-ganglionic)
What is the ventral ramus of T12?
The Subcostal nerve
T2 gives a large cutaneious branch that supplies what?
What is this branch called?
Supplies:
- Thorax wall in axilla
- Upper, medial part of UL
Called the Intercostobrachial Nerve
The ventral rami of T2-11 gives ___ _____ ____ at the angle of the rib which gives mainly motor to intercostal muscles
The ventral rami of T2-11 gives SMALL COLLATERAL BRANCH at the angle of the rib which gives mainly motor to intercostal muscles
What dermatome level are the following structures:
Xiphoid process?
Umbilicus?
Xiphoid process: T6
Umbilicus: T10
What is the treatment of a pneumothorax?
Presenting problem: The air is in the wrong place preventing the lung from expanding.
Treatment: A needle is inserted just above the rib to avoid damage to the neurovascular bundle that runs just inferior to each rib. Aim to go above/below and lateral to breast tissue.
Need passes through: Skin, pec major ( + pec minor?), 3 layers of intercostal muscles ( external, internal, innermost), endothoracic fascia, parietal pleura.
Function of the nose and nasal cavity?
Warm, humidify and filter inhaled air. Sense of smell
`What 3 cartilages support the nostrils/nares anteriorly?
Septal
Lateral
Alar (Lesser and Greater)
What is the function of the muscles around the nostrils? and what are they?
Act as sphincters/dilators to control the diameter of the nares and adjust air flow.
Muscles: Procerus, Nasalis, Levator Labii Superoiris Alaeque Nasi (muscles of facial expression)
Where are vibrissae located? and what is their function?
Location: On the skin of the nasal vestibule
Function: First air filters
What two structures are present on the lateral wall of the nasal cavity?
3 conchae (aka turbinates). Superior and middle from Ethmoid bone. Inferior from separate bone. Meati (area between overhanging conchae and cavity lateral wall).
[Adjacent paranasal air sinuses open into the meatu]
What bones make up the lateral wall of the nasal cavity?
Nasal, maxilla, macrimal, ethmoid, palatin, med. pterygoid plate of sphenoid
What bones make up the roof the nasal cavity?
Nasal, frontal, ethmoid, sphenoid
What is the function of conchae? What are they covered by?
Function: Increase surface area and create turbulence in the inhaled air.
Covered by highly vascular mucous membrane lined with respiratory epithelium (i.e. pseudostratified, ciliated, columnar with goblet cells)
What are the three skeletal elements of the medial wall- midline septum?
- Perpendicular plate of ethmoid
- Vomer
- Septal cartilage
Air passes through the ______ conchae (vom_, medial perpendicular plate of ____) into the nasopharynx
Air passes through the posterior conchae (vomer medial perpendicular plate of sphenoid) into the nasopharynx
The septum is ____ posteriorly and ________ anteriorly
The septum is bone posteriorly and cartilage anteriorly
The floor of the nasal cavity is horizontal and made up of the…….
Hard palate
What are the main components that make up the ethmoid bone?
- Superior, middle concha
- R + L ethmoidal labyrinth
- Perpendicular plate
- Bulla ethmoidalis
- Crista galli
- Cribriform plate
Fracture of the cribriform plate may cause ….
CSF rhinorrhoea
What structures lie immediately superior and later to the nasal cavity?
Superior: Cranial cavity
Lateral: 2 orbits
What sinus opens into middle meatus?
Maxillary sinus
[M=M]
What two structures bulge into the middle meatus?
Bulla ethmoidalis
Middle ethmoidal air cells
What epithelium detects smell? Where is it located?
Olfactory epithelium
Restricted to the cavity roof and the adjacent lateral wall and septum
The mucus from the sinuses and the tears from the eye empty into the _____, via the _______
The mucus from the sinuses and the tears from the eye empty into the meati, via the nasolacrimal duct
Nasal cavity and sinuses require what types of nervous supply?
General sensation and PS
Secretomotor supply to the mucous membrane
Cranial nerves arise in the _______ and emerge from _____ in the skull
Cranial nerves arise in the brainstem and emerge from foramina in the skull
What two cranial nerves provide sensory and parasympathetic (secretomotor) fibres?
The Trigeminal Nerve (Cranial V) is sensory. Has ophthalmic (V1) and maxillary (V2) divisions.
The Facial Nerve (Cranial VII) carries PS fibres that hitch-hike with divisions on trigeminal.
–> Divisions of the Trigeminal are distribution both the sensory and PS fibre
Where in the nasal cavity is olfaction restricted to?
The roof and over the superior concha
[Olfactory nerves are capable of regeneration]
Anterior/superior nasal nerves supplying the lateral wall of nasal cavity arise from?
From V1, mainly via the anterior ethmoidal nerve
Posterior/inferior nasal nerves supplying the lateral wall of nasal cavity arise from?
V2 mainly via the greater palatine nerve
Anterior/superior nasal nerves supplying the medial wall of nasal cavity arise from?
From V1
Posterior/inferior nasal nerves supplying the medial wall of nasal cavity arise from?
From V2 mainly via the nasopalatine nerve (enters the nasal cavity via the sphenopalatine foramen)
What artery accompanies and the following nerves and what do they branch from:
- Maxillary nerve (V2) branches?
- Ophthalmic nerve (V1) branches
- Branches of the Maxillary nerve (V2) are accompanied by branches of the maxillary branch of the external carotid artery
- Branches of the Ophthalmic nerve (V1) are accompanied by branches of the ophthalmic branch of the internal carotid artery
What nerve passes through the incisive canal to supply the anterior plate?
Nasopalatine nerve
Epistaxis, define?
Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx
What is the arterial supply of the:
- Anterior lateral nasal wall?
- Posterior lateral nasal wall?
Anterior:
-Anterior, superior branches from the anterior and posterior ethmoidal branches of the Ophthalmic Artery
Posterior:
-Posterior, inferior
branches from the
greater palatine and sphenopalatine branches of the Maxillary Artery
What is the one difference between the nervous and arterial supply of the nasal cavity?
The nasopalatine nerve is accompanied by the sphenopalatine artery
What is a key site of epistaxis?
Littles/Kiesselbach’s area on the septum as it is highly vascular
What features of the venous drainage of the nasal cavity increases likelihood of infection spread?
Connections to intracranial venous sinuses
- Nasal vein in foramen caecum
- Drainage to cavernous sinus in cranial cavity
- Also connects to cavernous sinus
What are the 3 paranasal sinuses?
Frontal sinuses
Ethmoidal cells
Sphenoidal sinuses
Maxillary sinuses
Entry of the sinuses and nasolacrimal duct?
Most enter the middle meatus
- Front sinus drains via the frontonasal duct and infundibulum (with anterior ethmoidal cells) to hiatus semilunaris
- Hiatus semilunaris inf. to bulla and extending to the infundibulum
- Maxillary sinus opens into the hiatus semilunaris (posteriorly)
- Bulla ethmoidalis with the openings of the middle ethmoidal air cells
What are the two pathologies that could lead to sinusitis?
Infection: The maxillary sinus opening is high in its medial wall and clearance of mucus is dependent upon ciliary action (which may be compromised by infection)
Deviated septum: Also predisposes to sinusitis
Which sinuses do NOT open into the middle meatus?
The posterior ethmoidal cells open into the superior meatus
The sphenoid sinus opens into the spheno-ethmoidal recess
The nasolacrimal duct opens into the inferior meatus
Arterial and nervous supply of the sinuses:
- Frontal, ethmoid and sphenoid?
- Maxillary?
The frontal, ethmoid and sphenoid sinuses are supplied by supra-orbital and ethmoidal branches of the Ophthalmic Nerve (V1) and Ophthalmic Artery
The maxillary sinus by branches of the Maxillary Nerve (V2) and Maxillary Artery
Posterior and anterior lymph drainage of the nasal cavity?
Anterior: Drains to submandibular nodes
Posteriorly: To upper cervical nodes via the retropharyngeal nodes
[Jugulodigastric is palpable if inflamed]
Describe the journey of inhaled air from nasal cavity to laynx
Inhaled air passes from the nasal cavity to the nasopharynx, which has protective, tonsillar tissue on its roof (adenoid), then past the soft palate to the oropharynx before entering the larynx
What is the larynx?
Protective sphincter that prevents foreign bodies entering the airway
What are tonsils?
Protective clusters of lymphoid tissue, the mucous membrane forms crypts
Adenoid/pharyngeal tonsil: On the roof and posterior wall of the nasopharynx
Tubal tonsil: Around the opening of the pharyngotympanic tube
+ Palatine and Lingual tonsils (below soft palate in oropharynx)
Enlargement/swelling of the following tonsils leads to:
- Pharnygeal tonsil?
- Tubal tonsil?
Inflammation and swelling of the pharyngeal tonsil may obstruct the airway and lead to mouth breathing
Enlargement of the tubal tonsil may obstruct the pharyngotympanic tube and cause middle-ear infections
Tonsillar lymph drainage is to the ??
Tonsillar lymph drainage is to the jugulodigastric node,
palpable behind
the angle of the
mandible
What structure separates the nasopharynx and oropharynx?
The soft palate
What is the larynx?
Amounts to a membranous (fibro-elastic) tube suspended between cartilages (the positions of which are controlled by muscles)
The laryngeal diameters may be altered to allow the passage of AIR ONLY, and also control airflow for SPEECH and raising INTRA-ABDOMINAL PRESSURE
What are the 4 laryngeal cartilages? ETAC
Epiglottic (elastic) - Most sup
Thyroid
Arytenoid
Cricoid (The only complete ring) - Most inf
[All hyaline cartilage except epiglottis]
What is the site of emergency access to the airway?
Median cricothyroid ligament (midline thickening of cricothyroid membrane)
5 features of the cricoid structure?
- Signet ring with the lamina posteriorly
- Articulates with the arytenoids and the thyroid
- “Sloping shoulder” on the lamina for arytenoid articulation
- Ridge for attachment of the oesophagus
- Depression for attachment of posterior crico-arytenoid muscle
Describe the lamina of the thyroid?
Left and right laminae
Each has superior and inferior horn (inf articulates with the cricoid)
The laminae fuse anteriorly as the laryngeal prominence, with superior notch above
[Prominence more obvious in males]
Epiglottis:
Attached to which other laryngeal cartilage?
Position?
Function?
Attaches to the thyroid cartilages
Position: Projects upwards into the pharynx, behind the posterior part of the tongue
Function: Laryngeal elevation during swallowing pushes the epiglottis backwards and downwards (closes laryngeal inlet). Spring back after swallowing
Arytenoid cartilage:
- Shape
- Articulates with…
- Topped by which cartilages?
- Contains which vocal structure?
Pyramidal shape. 3 sides and a base which articulates with the sloping shoulders of the cricoid lamina
Topped by corniculate and cuneiform cartilages
Vocal process anteriorly for attachment of the vocal ligament/fold
What are the laryngeal membranes?
- Extrinsic thyrohyoid membrane
2. Intrinsic: Quadrangular and Cricovocal/cricothyroid
The extrinsic thyrohyoid membrane:
Spans what area?
Thickenings?
Spans the space:
- FROM the upper edges of the thyroid lamina + superior
- TO the upper edges of the body + greater horn of the hyoid
Thickened anteriorly and posteriorly = Median and lateral thyrohyoid ligaments
What are the two intrinsic membranes/ligaments?
- Quadrangular: From arytenoid to thyroid + epiglottis. Forms Aryepiglottic ligament on upper edge.
- Cricovocal/cricothyroid from the cricoid + arytenoid to the thyroid. Forms the conus elasticus, median cricothyroid ligament and vocal ligament
How are the ligaments of the larynx turned onto folds?
Internal covering of mucous membrane
External muscle covering
What are the following folds formed over:
- Aryepiglottic fold?
- Vestibular fold?
- Vocal fold?
Aryepiglottic Fold: formed over the aryepiglottic ligament (upper edge of quadrangular membrane)
Vestibular Fold: formed over the vestibular ligament (lower edge of quadrangular membrane)
Vocal Fold: formed over the vocal ligament (upper edge of cricovocal (cricothyroid) membrane
Where is the laryngeal inlet found and what controls it’s opening/closure?
Formed by the aryepiglottic folds on each side of the quadrangular membrane
Closure via the elevation of the larynx and muscles within folds
What forms the folds of the laryngeal inlet?
False vocal / Vestibular folds on each side are the lower edge of the quadrangular membrane
Vocal folds (cords/ligaments) on each side are the upper edge of the cricovocal/cricothyroid membrane
Vocal folds control laryngeal diameter for??
Vital for which processes?
What muscles are involved in altering the diameter?
The vocal folds control laryngeal diameter for: speech, coughing, sneezing and raising the intra-abdominal pressure, which is vital in parturition, micturition, defecation and lifting heavy objects.
Muscles: Rima glottis/glottidis
The ventricle of the larynx is between the ______ and vocal folds and leads to the ______, which is to provide lubricating mucus for the ______ folds.
The ventricle of the larynx is between the VESTIBULAR and vocal folds and leads to the SACCULE, which is to provide lubricating mucus for the VOCAL folds.
Muscles involved in closing and opening the aryepiglottic folds i.e. the laryngeal inlet?
Closure:
- Elevation of the larynx and pharynx by extrinsic muscles from skull
- Aryepiglotticus: A continuation of oblique arytenoid
- Thyro-epiglotticus: Draws the epiglottis and arytenoids towards each other.
Open:
-Descent of larynx (and pharynx) mainly by elastic recoil
What action happens at the cricothyroid joint that lengthens/shortens the vocal folds?
The thyroid cartilage rocks backwards and forwards at the cricothyroid joint
What movements combine to separate the vocal folds and open the rima glottidis?
The arytenoid cartilages both swivel (or externally rotate) and glide laterally down the shoulders of the cricoid lamina
What is the only muscle that opens the rima glottis?
The posterior crico-arytenoid
What muscles are responsible for closing the rima glottis?
The arytenoids are pulled back up the cricoid shoulders towards each other (adduction) by TRANSVERSE ARYTENOID. and they cords are swivelled towards each other by LATER CRICO-ARYTENOID
What muscles are involved in lengthening and shortening the vocal folds to alter tension?
Shorten folds by rocking thyroid back towards the arytenoids: thyro-arytenoid
Lengthen folds by rocking thyroid forwards: cricothyroid
Increase in tension = Increase in voice pitch (vice versa)
What is the difference between rima glottis in quiet and forced inspiration?
Quiet: Triangular rima, all folds opens, all cords abducted
Forced: Rima more forcefully/widely opened by posterior crico-arytenoid
What is phonation/
When vocal folds are adducted to close the rima glottis and air is forced through, causing vibration.
Cord length and tensions are altered by an interplay between cricothyroid, thyro-arytenoid and vocalis
Laryngeal innervation?
The vagus (cranial X) sends the superior laryngeal nerve. Passes with the superior thyroid artery until it divides into the internal and external branches Internal branch: Sensation of larynx down to vocal folds External branch: Cricothyroid innervation
Recurrent laryngeal branch of the vagus:
Pathway?
Supplies?
Pathway:
- Passes inferior to aortic arch of the left, or subclavian artery on the right
- Ascends between the trachea and oesophagus
- intermingles with branches of the inferior thyroid artery close to the gland
- enters the larynx
Supplies: All the muscles of the larynx (except cricothyroid) and sensation to the vocal cords and larynx below
Laryngeal nerves may be at risk during…
Thyroid surgery
What are the different effects of nerve lesions:
- Complete paralysis of recurrent laryngeal
- Partial paralysis of RL
- Paralysis of external laryngeal
- Complete paralysis of the recurrent laryngeal – the vocal fold lies in a semi-abducted position. The fold vibrates so respiration is noisy, the voice is hoarse, but there is compensation by extra movement of the opposite fold
- Partial paralysis of the recurrent laryngeal causes the vocal fold to move into the midline and even cross it, therefore bilateral partial paralysis is life threatening
- Paralysis of the external laryngeal nerve may not be noticed, or there may be some hoarseness of the voice. Recovery is good due to hypertrophy of the opposite cricothyroid
What is the vascular supply and lymph drainage of the larynx?
Above vocal cords:
- Superior laryngeal branch of the superior thyroid artery
- Venous drainage to superior thyroid vein
- Lymph: Upper cervical nodes
Below vocal cords:
- Inferior thyroid artery
- Veins drain to the inferior thyroid vein
- Lymph: Lower deep cercial nodes
The inferior thyroid veins are at risk in….
The inferior thyroid veins are at risk in tracheostomy as they descend to the left brachiocephalic vein
What structures make up the:
- Conducting pathway?
- Respiratory pathways?
Conducting: Nasal cavity and mouth, larynx into the trachea, RMB and LMB, lobar bronchi, segmental bronchi
Respiratory: Respiratory bronchioles, alveolar duct, alveoli
The walls of the bronchioles and alveolar ducts are composed of….
- Ciliated cuboidal epithelium becoming simple
- Squamous epithelium
- Elastic fibres
- Smooth muscle
NB there is no cartilage and no bronchial glands
