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Chest Wall and LungAnatomy and
Physiology
Zeyad S Alharbi, M.D.
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Anatomy and Physiology of the Thorax
Thoracic Skeleton 12 Pair of C-shaped Ribs
Ribs 1-7: Join at sternum with cartilage end-points Ribs 8-10: Join sternum with combined cartilage at 7thrib
Ribs 11-12: No anterior attachment Sternum Manubrium
Joins to clavicle and 1strib
Jugular Notch
Body Sternal angle (Angle of Louis)
Junction of the manubrium with the sternal body
Attachment of 2ndrib
Xiphoid Process Distal portion of sternum
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Anatomy and Physiology of the Thorax
Thoracic Skeleton Topographical Thoracic Reference Lines
Midclavicular line Anterior axillary line
Mid-axillary line Posterior axillary line Intercostal Space
Artery, Vein and Nerve on inferior margin of each rib Thoracic Inlet
Superior opening of the thorax
Curvature of 1st
rib with associated structures Thoracic Outlet
Inferior opening of the thorax 12thrib and associated structures & Xiphisternal joint
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Blood Supply and Innervation
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Anterior Chest Wall Deformities
1. Pectus excavatum 2. Pectus carinatum
3. Polands syndrome 4. Sternal defects 5. Miscellaneous
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Etiology and Incidence of Pectus Excavatum
It is reported 1/700 of lives birth M:F=3.4:1
37% occur in Families with Chest walldeformities It is a posterior depression of the sternum and
costal cartilage due to over grow of costal
cartilage The 1stand 2ndribs, manubrium are in normalposition
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M-S Abnormalities with Pectus Excavatum
Scoliosis Kyphosis
Myopathy Marfans syndrome Cerebral palsy Prune-belly syndrome Tuberous sclerosis
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Symptoms of Pectus Excavatum
Decreased exercise tolerance Fatigability
Dyspnea on exertion, and sternal pain Palpitations and multiple respiratory tract
infections are reported
MOST complaint : cosmetic deformityrather than symptomatology
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Pectus Carinatum
( Pigeon Chest )
It refers to anterior protrusion of the sternum
It is less common than pectus excavatum
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Categories of Pectus Carinatum
1. Chondrogladiolar
(I) It is the most common pectus carinatum
(II) It consists of anterior protrusion of
the body of sternum and lower costalcartilages
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(2) Lateral Pectus Carinatum :a unilateral protrusion of the costal cartilages and
is usually accompanied by sternal rotation to the
opposite side
(3) Chondromanubrial:(I) Uncommon
(II) Protrusion of Manubrium,2ndand 3rdcostal cartilages withrelative depression of the body andsternum
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Polands Syndrome1841
It refers to a congenital absence of thepectoralis major and minor muscles, ribs,
breast abnormality, chest wall depressionand syndactyly, brachydactyly or absenceof phalanges
It is present in 1/30000 The etiology is unknown
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Thoracic Outlet Syndrome TOS
Cervical Rib:
0.5-1% population (not allare symptomatic)
Neurogenic symptoms95%
Ulnar nerve C8-T1 is usuallyaffected
Vascular Symptoms 5% Subclavian artery
Subclavian vein
{cervical rib between the transverse
process of C7 & the 1strib. You can
see the cervical rib in the other side
elevating the brachial plexus.}
{Definition of cervical rib: an accessory rib
which is not normally present. If present itmay cause compression of important
structures in the thoracic outlet.}
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Vascular Symptoms of TOSSubclavian Artery:
Prolonged compression & trauma
Intimal injury
Stenosis, Thrombosis
Post-stenotic Dilatation or Aneurysm
Distal Micro-embolisation
BandCervical
Rib
{In Unilateral Raynauds alwayssuspect TOS, because usuallyRaynauds phenomenon issystemic & will cause bilateralsymptoms}
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Depending on the surgeons preference, there are 2 approachesfor the surgery:
Supraclavicular Approach: Scalenectomy
Excision of 1strib & fibrous bands
Repair of subclavian artery if its injured and patient has vascular
problems: Thrombectomy, patch angioplasty Excision of aneurysm & bypass graft
{scalenectomy & 1strib excision are enough in those with
neurological symptoms}
Transaxillary Approach: Excision of 1strib. This causes the brachial to go down a little relieving
the compression
Surgical Treatment of TOS
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The Respiratory Muscles
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Anatomy and Physiology of the Thorax
Pleura:appears between the 4th and 7th gestational weeks
Visceral Pleura Cover lungs
Parietal Pleura Lines inside of thoracic cavity.
Pleural Space
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The relationships of the pleural reflections andthe lobes of the lung to the ribs that at the
midclavicular line, the recess is between ribspaces 6 and 8, at the midaxillary line between8 and 10 and at the paravertebral line between10 and 12.
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LungsGross Anatomy Paired, cone-shaped organs in thoracic
cavity Separated by heart and other
mediastinal structures
Covered by pleura Extend from diaphragm inferiorly tojust above clavicles superiorly
Lies against thoracic cage (pleura,muscles, ribs) anteriorly, laterally andposteriorly
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LungsGross Anatomy
Hilum Medial root of the lung
Point at which vessels, airways and lymphaticsenter and exit
Cardiac Notch
Lies in medial part of left lung toaccommodate the heart
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Lobes and Fissures
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LungBlood Supply
Dual Supply Bronchial Supply: arises from superior
thoracic aorta or the aortic arch. Supply bronchi, airway airway walls and pleura
Pulmonary Supply
Pulmonary arteries enter at hila and branchwith airways
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Lymphatics
Lymphatic drainage follows vessels Parabronchial (peribronchial) lymphatics
and nodes hilar nodes mediastinalnodes pre- and para-tracheal nodes supraclavicular nodes
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Anatomy and Physiology of the Thorax
Mediastinum Central space within thoracic cavity
Boundaries Lateral: Lungs Inferior: Diaphragm Superior: Thoracic inlet
Structures Heart Great Vessels Esophagus Trachea
Nerves Vagus
Phrenic
Thoracic Duct
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Respiratory Center in ReticularFormation of the Brain Stem Medullary Rhythmicity Center
Controls basic rhythm of respiration
Inspiratory (predominantly active) andexpiratory (usually inactive in quietrespiration) neurones
Drives muscles of respiration
Pneumotaxic Area Inhibits inspiratory area
Apneustic Area Stimulates inspiratory area, prolonging
inspiration
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Regulation of Respiratory Center
Chemical Regulation Most important
Central and peripheral chemoreceptors
Most important factor is CO2 (and pH)
in arterial CO2 causes in acidity of
cerebrospinal fluid (CSF)in CSF acidity is detected by pH sensors
in medulla
Medulla rate and depth of breathing
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Regulation of Respiratory Center
Cerebral CortexVoluntary regulation of breathing
Inflation Reflex Stretch receptors in walls of bronchi/bronchioles
Respiratory Centers and Reflex Controls
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Figure 23.27
Respiratory Centers and Reflex Controls
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Pulmonary function is affected by lungresection, extent varies:
pneumonectomy:
FEV1: 34~36% FVC: 36~40%VO2max: 20~28%
lobectomy:
FEV1: 9~17% FVC: 7~11%VO2max: 0~13%
Am J o f Med (2005) 118, 578583
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