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Anatomy: Lungs and Plurae

Anatomy: Lungs and Plurae

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Published by Ditas Aldover Chu

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Published by: Ditas Aldover Chu on Sep 29, 2009
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12/24/2012

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1
The Pleura
•Serous layer of mesothelium that invest &enclose each lung•Visceral pleura – lines the lung itself •Parietal pleura – lines the chest wall•Pleural cavity – contains a layer of serous pleural fluid for lubrication (
100mL produced and absorbed daily )
THE PARIETAL PLEURA
•Costal pleura – in the ribs•Mediastinal pleura•Diaphragmatic pleura – on top of the diaphragm•Cervical pleura/suprapleural membraneLeft:
Pleural reflection moves laterally
 fromthe midline
then inferiorly up to the 6
th
 costal cartilage
Left lung is more deeply indented by thecardiac notchRight:
Pleural reflection continues inferiorlyfrom 4
th
to 6
th
costal cartilage
Lung parallels pleural reflection closely
 Pleural reflection pass:-lateral at 6 
th
rib-reach the Midclavicular line at 8
th
costal cartilage-10
th
rib at Midaxillary line-12
th
rib at the scapular line Inferior Margin of the lungs reach:-Midclavicular line at 6 
th
rib-Midaxillary line at 8
th
rib-Scapular line at 10
th
ribClinical Importance: Posteriorly the pleural may go beyond the costal margin – Prone to injury during abdominal  surgery During kidney surgery, injury to the pleura mayoccur and cause air to enter into the thoracic or  pleural cavitySurgical pleurae/Pleural Cupola – covering inthe apical area
 Right and left 
Gross Anatomy Lungs and Pleurae
 
2
Most superior part is below the 1
 st 
rib but never above the neck of the 1
 st 
rib
 Extends in the superior thoracic apertureto go to the neck 
 Dome shaped groove
 Because of position,if there is injury toneck (laceration, gunshot wound, ice pick), the pleural may also be injured and also the underlying lung. Pleura reflection ends 2 finger breaths above themost inferior costal margin
Pleural Recesses
•On full inspiration – lungs fill up cavities•Quiet respiration – 3 parts not occupied•Area of acute P R – “parietal on parietal pleurareflection”-R&L Costodiaphragmatic recesses-Costomediastinal Recess
Disorders of the Pleura
 Hydrothorax-fluid accumulation in the thorax or pleural cavity
-can be anything ie. blood, chyle, pus
-as fluid increases the lungs will be morecollapsed and near the hilum-if you want to breath you can’t utilize the whole parenchyma because its squished -the fluid prevents expansion
Classic signs:•Dullness on percussion•Decreased breath sounds•Mediastinal displacement- (
organs are pushed to the other side)
•Transudate vs Exudate•Total protein 0.5•LDH 0.6•Unilateral or Bilateral
Transudate(
high pressure)
Exudate
Common causes:•Congestive heartfailure•Renal insufficiency•CirrhosisTreat the primarycause- Correct fluid balanceCommon causes:•Infection•Malignancy•Treatment:•Drainage•Antibiotics (for  parapneumonic effusionsand empyemas)•Pleurodesis (for malignant effusions)
Thoracentesis
 Draining the fluid in the thorax w/ aneedle
Patient’s back to Physician w/ elbowsforward & raised 90°
Allows to move scapula tip laterally – away from field of puncture
Insert needle on appropriate ICS~top of rib (
decrease chances of hitting the VAN bundle)
Pneumothorax
-normal parenchyma balloons
Usually due to rupture of subpleural cystor bulla
Air in the pleural space
Primary:
it just happened 
Secondary:
 pt has an already existing lung problem
Pt is usually dyspneic, breath soundsabsent or decreased
Other PE…???
Tachypnia, eyes areenlarged, engorged neck vein
Gross Anatomy Lungs and Pleurae
 
3
Diagnosis is confirmed with chest xray•Treatment: –Drainage with a chest tubeFor persistent air leaks or recurrences: –Video Assisted Thoracoscopic Surgery (VATS) –Thoracotomy –Oversewing of bleb –Pleural scarification/abrasion
Hemothorax
 Accumulation of blood in the thorax
Usually seen in chest trauma, blunt or  penetrating
Anticoagulant therapy
Treatment
Chest tube drainage
 For trauma cases:
Thoracotomy for control of hemorrhage (>200ml/hr drainage)
 Blood can rise and fill upthe whole lungsuntil it collapse.
Empyema Thoracis -
 pus
Develops from untreated or inadequatelytreated parapneumonic effusions
Post op patients (lung resections or pleural procedures)*
 pus has its own lining 
Empyemectomy - removing the pus as awhole
Decortication – prolonged cases; pus hashardened;
 stripping the lining out of the lung in order for the lungs to expand again
Chylothorax
Accumulation of lymph in the pleural cavity
Tumor 
Injury to Thoracic Duct (
the aqueduct of thelymph
)
If persistent beyond 3 to 4 weeks
Ligation of Thoracic Duct
Talc PleurodesisPleuroperitoneal shunt – 
direct chyle tothe peritoneum to the abdomen to beabsorbed 
The Lungs
Essential organs of respiration
 Normally light, soft & spongy
Left & Right separated fr @ other bymediastinum
Attached: heart & trachea by the “root of thelung”Inferior Pulmonary ligament
-cardiopulmonary machine - lung surgery-in newborns: light and spongy-mediastinum in the middle - no communicationbet. R&L lungsTrachea connects to the lung itself 
Surface Anatomy
Cervical pleurae & apices
Pass through superior thoracic apertureinto the supraclavicular fossa
Anterior borders of lungs
Adjacent to anterior lines of reflection of the parietal pleura up to level of 4
th
costalcartilages
FissuresOblique
- extends from spinous process of T2 vertebra to6
th
costal cartilage- Coincides w/3 vertebral border of scapula whenarm is elevated
Horizontal
- is at the 4
th
rib & costal cartilage anteriorlyGross Anatomy Lungs and Pleurae

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