TRACHEOBRONCHIAL TREE

• The lung has a spongy parenchyma containing the

bronchial tree
Bronchial tree
• A highly branched system of air tubes extending from the
primary bronchus to about 65,000 terminal bronchioles
• The trachea is a flexible tube that extends from vertebral
level CVI in the lower neck to vertebral level TIV/V in the
mediastinum
 The trachea is held open by horseshoe or 'C-shaped'
cartilage rings
 The posterior wall of the trachea is smooth muscle
 It bifurcates into right and left main bronchus
 Each main bronchus enters the root of a lung through the
hilum
 The right main bronchus is wider and takes a more vertical
course than the left main bronchus
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 Bronchial tree …
• The main bronchus divides within the
lung into lobar bronchi (secondary
bronchi), each of which supplies a
lobe
 On the right side, the lobar bronchus
to the superior lobe originates within
the root of the lung
 Further divide into segmental
bronchi (tertiary bronchi), which
supply bronchopulmonary segments
 Within each bronchopulmonary
segment, the segmental bronchi →
bronchioles, which further subdivide
and supply the respiratory surfaces.
 The walls of the bronchi are held by
discontinuous plates of cartilage, but
not present in bronchioles 3
 Trachea
↓
Right primary bronchus Left primary
bronchus
↓ ↓
3 Lobar bronchi 2 Lobar bronchi
↓ ↓
10 segmental bronchi 8--10 segmental
bronchi
Bronchioles
↓
Terminal Bronchioles
↓
Respiratory Bronchioles
↓
Alveolar ducts
↓
Alveolar sac
↓
Alveolus

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 Bronchopulmonary segment cont’d…

• A bronchopulmonary segment is smallest irregular cone

shape area of the lung with the apex and base
• The bronchopulmonary segments are:
 The segment is the smallest and functionally
independent region of a lung
 Separated from adjacent segments by connective
tissue septa
 Supplied independently by a segmental bronchus
and a tertiary branch of the pulmonary artery
 They can be isolated and removed without affecting
adjacent regions(Surgically resectable)
 There are ten bronchopulmonary segments in each
lung ;some of them fuse in the left lung may become
eight 9
Bronchopulmonary segments

10
 Bronchopulmonary segments…
Right Lung
Superior (upper) lobe:
– Apical
– Posterior
– Anterior
Middle lobe
– Lateral
– Medial
Inferior (lower) lobe:
– Superior (apical)
– Medial basal
– Anterior basal
– Lateral basal
– Posterior basal
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Bronchopulmonary segment…
Left Lung
Superior (upper) lobe:
– Apical
Apicoposterior
– Posterior
– Anterior
– Superior lingular
– Inferior lingular
Inferior (lower) lobe:
– Superior (apical)
– Anterior basal
– Medial basal Anteromedial basal

– Lateral basal
– Posterior basal
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Bronchial tree …
Bronchioles
• Are continuations of the airway that are
1mm in diameter and lack cartilage
• A well developed layer of smooth
muscle in their walls enables them to
dilate or constrict

• Each bronchiole divides into terminal bronchioles, the final

branches of the conducting division
 They measure 0.5 mm in diameter and have no mucous glands
or goblet cells
 They do have cilia so that mucus draining into them can be
driven back by the mucociliary escalator
 Thus preventing congestion of the terminal bronchioles and alveoli

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Bronchial tree …
• Each terminal bronchiole gives
respiratory bronchioles
 They mark the beginning
of the respiratory division
• All branches of the respiratory
division are defined by the
presence of alveoli

• The respiratory bronchioles

have scanty smooth muscle,
and the smallest of them are
no ciliated
 Each divides into 2-10 elongated, thin-walled passages called
alveolar ducts that end in alveolar sacs, which are grapelike
clusters of alveoli
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 Alveoli
• Each human lung is a
spongy mass composed of
250 – 300 million little
sacs, the alveoli, which
provide about 70 m2 of
surface area for gas
exchange
• An alveolus is a pouch
about 0.2 to 0.5 mm in
diameter

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 Blood Vessels and Nerves of the Lung
Pulmonary arteries
• They originate from the
pulmonary trunk
• Carry deoxygenated blood
in to the lungs from the right
ventricle of the heart

Right pulmonary artery

• The right pulmonary artery is longer than the left and passes
horizontally across the mediastinum). It passes:
 Anterior and slightly inferior to the tracheal bifurcation and anterior to
the right main bronchus
 Posterior to the ascending aorta, superior vena cava, and upper right
pulmonary vein 16
Pulmonary arteries …
• The right pulmonary artery
enters the root of the lung
and gives off a large branch to
the superior lobe of the lung
• Continues through the hilum,
gives off a second (recurrent)
branch to the superior lobe,
and then divides to supply the
middle and inferior lobe

Left pulmonary artery

• Is shorter than the right
• Lies anterior to the descending aorta
• It passes through the root and hilum and branches within the lung

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Pulmonary veins
• On each side a superior and an inferior pulmonary vein
carry oxygenated blood from the lungs back to the
heart
• The veins begin at the hilum, pass through the root and
immediately drain into the left atrium

Bronchial arteries and veins

• Bronchial arteries supply blood for nutrition of the
structures making up the root of the lungs, the
supporting tissues of the lungs, and the visceral pleura
• They interconnect within the lung with branches of the
pulmonary arteries and veins
• The bronchial arteries originate from the thoracic aorta
or one of its branches:
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Bronchial arteries and veins …
• A single right bronchial artery normally arises
from the third posterior intercostal artery
• Two left bronchial arteries arise directly from
the anterior surface of the thoracic aorta-
 The superior left bronchial artery arises at vertebral
level TV, and the inferior one inferior to the left
bronchus
• Bronchial arteries run on the posterior surfaces
of the bronchi, ramify in the lungs to supply
pulmonary tissues
The bronchial veins
• They drain into
 Either the pulmonary veins or the left atrium
 Into the azygos vein on the right or into the superior
intercostal vein or hemiazygos vein on the left
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 Innervation of the Lung
• The visceral pleura and other structures of the
lung are innervated by:
 Visceral afferents and efferents through the anterior
and posterior pulmonary plexus
o These plexuses lie anteriorly and posteriorly to the
tracheal bifurcation and main bronchi
 The anterior plexus is much smaller than the posterior
plexus
o Branches of these plexuses originate from the
sympathetic trunks and vagus nerves, are distributed
along branches of the airway and vessels
 Visceral efferents from:
 The vagus nerves constrict the bronchioles and vasodilator
 The sympathetic system dilate the bronchioles and
vasoconstrictor (pulmonary vessels)
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Innervation of the Lung

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 Lymphatic drainage of lungs
• Superficial, or
subpleural, and
deep lymphatics of
the lung drain into
tracheobronchial
nodes around the
roots

 As a group, these
lymph nodes
extend from the
lung, through the  Efferent vessels from tracheobronchial
hilum and root, nodes pass superiorly to right and left
and into the bronchomediastinal trunks
posterior  These trunks drain directly into deep veins at the
mediastinum base of the neck, or may drain into the right
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lymphatic trunk or thoracic duct
Lymphatic drainage

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 Clinical consideration
Chest Pain
- can result from pulmonary disease
- may also occur in intestinal, gallbladder, and
musculoskeletal disorders.
- is probably the most important symptom of
cardiac disease
In people with a heart attack, the associated
pain is described as a ‘crushing’ sub-sternal
pain (deep to the sternum) that does not
disappear with rest
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 Rib Fractures
- Rib fractures usually result from blows or from crushing
injuries
- The middle ribs are most commonly fractured.
- The weakest part of a rib is just anterior to its angle; and
its broken end may injure internal organs such as a lung
or spleen.
Variation of ribs
• Number:- increased by development of cervical or
lumbar ribs or decreased by failure of the 12th rib to
develop
• Shape:- bifid ribs

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 Dislocation of Ribs
A rib dislocation (slipping rib syndrome) is the
displacement of a costal cartilage from the
sternum (dislocation of a sternocostal joint) or
the displacement of the interchondral joints.
Complications may result from pressure on or
damage to nearby nerves, vessels, and muscles.
injuries to underlying structures such as the
diaphragm or liver, causing severe pain,
particularly during deep inspiratory movements.
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 Separation of Ribs
 Rib separation refers to dislocation of a
costochondral junction between the rib and
its costal cartilage.
 In separations of the 3rd-10th ribs, tearing of
the perichondrium and periosteum usually
occurs.
 As a result, the rib may move superiorly,
overriding the rib above and causing pain.

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 Flail Chest
- Multiple rib fractures may allow a sizable
segment of the anterior and/or lateral thoracic
wall to move freely.
- The loose segment of the wall moves
paradoxically (inward on inspiration and
outward on expiration).
- Flail chest (stove-in chest) is an extremely
painful injury and impairs ventilation, thereby
affecting oxygenation of the blood.
- During treatment, the loose segment is often
fixed by hooks or wires so that it cannot move.
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 Thoracotomy
• The surgical creation of an opening through the
thoracic wall to enter a pleural cavity is a
thoracotomy.
This may involve:
 an anterior thoracotomy which cuts through the
perichondrium of one or more costal cartilages
 a posterior thoracotomy – an incision thru the
posterolateral aspects of the 5th-7th intercostal
spaces.
 a lateral thoracotomy - most satisfactory
approach for entry into the thoracic cage.

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 Median Sternotomy

 To gain access to the thoracic cavity for surgical

operations in the mediastinum, the sternum is split in
the median plane and retracted.
 Used for coronary artery bypass grafting, removal of
tumors in the superior lobes of the lungs, etc.

Sternal Biopsy
 The sternal body is often used for bone marrow
needle biopsy because of its breadth and
subcutaneous position.
 Sternal biopsy is commonly used to obtain specimens
of marrow for transplantation and for detection of
metastatic cancer and blood dyscrasia (abnormalities).
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 Vertebral Column
in • Normal Curvature
– Cervical Region = Concave curve
– Thoracic Region = Convex curve
– Lumbar Region = Concave curve
– Sacrum and coccygeal = Convex curve
out
• Abnormal Curves
– Scoliosis-abnormal lateral curve > 10°,
“twisted disease”
– Kyphosis -exaggerated thoracic curve,
in “humped disease”
– Lordosis -accented lumbar curve, “bent-
backward disease”
out

30-May-18 1:45:58 PM 34
Vertebral Column

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 Cont’d
Thoracic outlet syndrome
• Clinically, it’s used to describe symptoms
resulting from
Abnormal compression of the brachial
plexus of nerves as it passes over the first
rib and through the axillary inlet into the
upper limb
 The anterior ramus of T1 passes superiorly
out of the superior thoracic aperture to
join and become part of the brachial plexus
• The cervical band from a cervical rib is
one cause of thoracic outlet syndrome
The band puts upward stresses on the
lower parts of the brachial plexus as they
pass over the first rib
 Dyspnea: Difficult Breathing
 When people with respiratory problems (e.g.,
asthma) or with heart failure struggle to
breathe, they use their accessory respiratory
muscles to assist the expansion of their
thoracic cavity.
They lean on their knees to fix their pectoral
girdle so these muscles are able to act on their
rib attachments and expand the thorax.

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 Thoracoscopy
 Thoracoscopy is a procedure in which the
pleural cavity is examined with a thoracoscope
 Small incisions are made into the pleural
cavity via an intercostal space.
 Biopsies can be taken and some thoracic
conditions can be treated.

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 Intercostal Nerve Block
 Local anesthesia of an intercostal space is produced by
injecting a local anesthetic agent around the intercostal
nerves between the paravertebral line and the area of
required anesthesia = an intercostal nerve block.
- This involves infiltration of the anesthetic around the
intercostal nerve trunk and its collateral branches
- Because any particular area of skin usually receives
innervation from two adjacent nerves, considerable
overlapping of contiguous dermatomes occurs.
 Therefore, complete loss of sensation usually does not
occur unless two or more intercostal nerves are
anesthetized.
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Intercostal Nerve Block…

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 Insertion of a Chest Tube

 Major amounts of air, blood, serous fluid, pus or

any combination of these substances in the
pleural cavity are typically removed by placement
of a chest tube.
 A short incision is made in the 5th or 6th
intercostal space in the midaxillary line (~ at
nipple level).
 Removal of air allows reinflation of a collapsed
lung.
 Failure to remove fluid may cause the lung to
develop a resistant fibrous covering that inhibits
expansion unless it is peeled (lung decortication).
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 Pneumothorax
- Entry of air into the pleural cavity results from:
 A penetrating wound of the parietal pleura or rupture of a
lung
 Fractured ribs may also tear the parietal pleura and produce it
 Leakage from the lung through an opening in the visceral
pleura

Hydrothorax
- Accumulation of fluid in the pleural cavity, may result from:
 Pleural effusion (escape of fluid into the pleural cavity)

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Collapsed lung

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Case of right-sided pleural effusion

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 Hemothorax
- With a chest wound, entry of blood (results more
often from injury to a major intercostal vessel
Chylothorax
- lymph from a torn thoracic duct may enter the
pleural cavity
Chyle, a pale white or yellow lymph fluid in the
thoracic duct containing fat absorbed by the
intestines

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 Pleuritis
• Normally the moist, smooth pleurae make no sound
detectable by auscultation. However, inflammation of the
pleurae, pleuritis (pleurisy) makes the lung surfaces
rough
 The resulting friction (pleural rub) may be heard with
a stethoscope
Acute pleuritis is marked by sharp, stabbing pain,
especially on exertion, such as climbing stairs,
when the rate and depth of respiration may be
increased even slightly

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 Thoracocentesis
• Obtaining a sample of pleural fluid or to remove blood or pus from
the pleural cavity
 By a hypodermic needle through an intercostal space (mostly
the 9th in the midaxillary line is safe)
 To avoid damage to the intercostal nerve and vessels, the needle is
inserted superior to the rib, high enough to avoid the collateral
branches

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 Lung Resections
 Knowledge of the anatomy of the
bronchopulmonary segments is essential for
surgical resection of diseased segments.
 Bronchial and pulmonary disorders such as
tumors or abscesses (collections of pus) often
localize in a bronchopulmonary segment, which
may be surgically resected.
During treatment of lung cancer, the surgeon
may remove a whole lung (pneumonectomy), a
lobe (lobectomy) or a bronchopulmonary
segment (segmentectomy).
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 Pulmonary Embolism
• Obstruction of a pulmonary artery by a blood
clot
• An embolus forms when a blood clot, fat globule,
or air bubble travels in the blood --- to a lung via
a pulmonary artery
 The embolus may block a pulmonary artery or one
of its branches. The immediate result is
 Partial or complete obstruction of blood flow to the lung
 When a large embolus occludes, the person suffers acute
respiratory distress
 This is because of a major decrease in the
oxygenation of blood owing to blockage of blood
flow through the lung 50
 Bronchogenic Carcinoma
 Refers to any lung cancer
 Mainly caused by cigarette smoking
 Most cancers arise in the mucosa of the large bronchi
and produce a persistent, productive cough or
hemoptysis (spitting of blood).
 The primary tumor metastasizes early to the
bronchopulmonary (hilar) lymph nodes and
subsequently to other thoracic lymph nodes.
• The tumor cells probably enter the systemic circulation
by invading the wall of a sinusoid or venule in the lung
 And transported through the pulmonary veins, left heart,
and aorta to all parts of the body, especially the cranium
and brain
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Bronchoscopic evaluation.

A. Of the lower end of the trachea and its main branches. B. Of tracheal bifurcation 52
showing a tumor at the carina.
 Variations in the Lobes of the Lung

 Occasionally, an extra fissure divides a lung or a fissure

is absent.
For e.g., the left lung sometimes has three lobes and the
right lung only two.
 The most common accessory lobe is the azygos lobe,
which appears in the right lung in approximately 1% of
people.
• In these cases, the azygos vein arches over the apex of
the right lung and not over the right hilum, isolating the
medial part of the apex as an azygos lobe.

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 Auscultation of the Lungs and
Percussion….

 Auscultation and percussion should always

include the root of the neck where the apices of
the lungs are located.
 When clinicians refer to auscultating the base of
the lung, they are usually referring to the
inferoposterior part of the inferior lobe.
 In this case, the clinician applies a stethoscope to
the posterior thoracic wall at the level of the 10th
thoracic vertebra.

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 Aspiration of Foreign Bodies
 Because the right bronchus is wider and shorter
and runs more vertically than the left bronchus,
foreign material (e.g., a foreign body or food) is
more likely to enter and lodge in it or one of its
branches.
 A potential hazard encountered by dentists is an
aspirated foreign body, such as a piece of tooth or
filling material, that is likely to enter the right
main bronchus.
 To create a sterile environment and avoid
aspiration of foreign objects, dentists may insert
a thin rubber dam into the oral cavity during
procedures.
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 Bronchoscopy
 Bronchoscopy is a procedure that looks inside the lung
airways. It involves inserting a bronchoscope tube
 A cartilaginous projection of the last tracheal ring, the
carina is observed between the orifices of the main
bronchi.
 If the tracheobronchial lymph nodes in the angle between
the main bronchi are enlarged because cancer cells have
metastasized from a bronchogenic carcinoma, for e.g., the
carina is distorted, widened posteriorly, and immobile.
 Hence, morphological changes in the carina are important
diagnostic signs to bronchoscopists in assisting with the
differential diagnosis of respiratory disease.
 The mucous membrane covering the carina is one of the
most sensitive areas of the tracheobronchial tree and is
associated with the cough reflex.
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 Pleural Pain
 The visceral pleura is insensitive to pain
because it receives no nerves of general
sensation.
 The parietal pleura (particularly the costal
part) is extremely sensitive to pain.
The parietal pleura is richly supplied by
branches of the intercostal and phrenic
nerves.

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 Pleural Pain…
 Irritation of the parietal pleura may produce local
pain or referred pain projected to dermatomes
supplied by the same spinal (posterior root) ganglia
and segments of the spinal cord.
 Irritation of the costal and peripheral parts of the
diaphragmatic pleura results in local pain and
referred pain to the dermatomes of the thoracic
and abdominal walls.
 Irritation of the mediastinal and central
diaphragmatic areas of parietal pleura results in
referred pain to the root of the neck and over the
shoulder (C3-C5 dermatomes).
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