NERVOUS SYSTEM PART 1
FUNCTIONAL
ORGANIZATION OF THE
NERVOUS TISSUE
FUNCTIONS OF THE NERVOUS
SYSTEM
1. Maintaining homeostasis
 The trillions of cells in the
human body do not function
independently of each other
but must work together to
maintain homeostasis.
2. Receiving sensory input
 Sensory receptors monitor
numerous external and
internal stimuli. We are
aware of sensations from
some stimuli, such as sight,
hearing, taste, smell, touch,
pain, body position, and
temperature. Other stimuli,
such as blood ph, blood
gases, and blood pressure, are
processed at an unconscious
level.
3. Integrating information
 The brain and spinal cord are
the major organs for
processing sensory input and
initiating responses.
4. Controlling Muscles and Glands
 Skeletal muscles normally
contract only when
stimulated by the nervous
system. The nervous system
controls the secretions from
many glands, including sweat
glands, salivary glands, and
the glands of the digestive
system.
5. Establishing and Maintaining
Mental Activity
 The brain is the center of
mental activities, including
consciousness, thinking,
memory, and emotions.
MAIN DIVISIONS OF NERVOUS
SYSTEM
 Central Nervous System
(Cns) consists of the brain
and the spinal cord.
 Peripheral Nervous System
(Pns) consists of cranial
nerves, which arise from the
brain, and spinal nerves,
which arise from the spinal
cord.
 Sensory Receptors are the
endings of neurons, or
separate, specialized cells
that detect temperature,
pain, touch, pressure, light,
sound, odor, and other
stimuli.
 Nerve is a bundle of nerve
fibers, called axons, and their
sheaths; it connects the cns
to sensory receptors,
muscles, and glands.
 There are 12 pairs of cranial
nerves that originate from
the brain and 31 pairs of
spinal nerves that originate
from the spinal cord
 A ganglion is a collection of
neuron cell bodies located
outside the cns.
 Plexus is an extensive
network of axons and, in
some cases, neuron cell
bodies, located outside the
cns.
TWO FUNCTIONAL
SUBDIVISIONS OF PNS
• Sensory division, or afferent
division, transmits electrical signals,
called action potentials, from the
sensory receptors to the cns.
 • The cell bodies of sensory neurons
are located in dorsal root ganglia
near the spinal cord or in ganglia
near the origin of certain cranial
nerves.
• The motor division, or efferent
division, transmits action potentials
from the cns to effector organs, such
as muscles and glands.
• The motor division is divided into
two subdivisions: somatic nervous
system and the autonomic nervous
system (ans).
MOTOR DIVISION OF PNS
• The somatic nervous system allows
us to consciously control
movements of our skeletal muscles
through action potentials that
originate in the cns and are
transmitted by the somatic nervous
system to the same skeletal
muscles.
• The ans controls our unconscious
activities, such as contractions of
smooth muscle, cardiac muscle, and
secretion by certain glands.
• The ans has two sets of neurons in a
series between the cns and the
effector organs.
DIVISIONS OF ANS
 Sympathetic division is most active
during physical activity
 Parasympathetic division regulates
resting functions, such as digesting
food or emptying the urinary
bladder.
ENS
• Enteric nervous system (ens)
consists of plexuses within the wall
of the digestive tract.
• A unique feature of enteric neurons
is that they monitor and control the
digestive tract independently of the
cns through local reflexes.
• The cns can override enteric
functions via parasympathetic and
sympathetic actions.
CELLS OF THE NERVOUS
SYSTEM
• Neurons, or nerve cells, receive
stimuli and transmit action
potentials to other neurons or to
effector organs.
• The cell body is called the neuron
cell body, or soma, the cell body’s
nucleus is the source of information
for protein synthesis.
• Dendrite, referring to its branching
organization.
• Axon, referring to the straight
alignment and uniform diameter of
most axons. Axons are also called
nerve fibers.
NEURONS
• Cell body contains a single,
relatively large, and centrally
located nucleus with a prominent
nucleolus.
• Dendrite – which is a cytoplasmic
extension from the cell body, that
usually receives information from
other neurons and transmits the
information to the cell body.
• Axon – which is a single long cell
process that leaves the cell body at
the axon hillock and conducts
sensory signals to the cns and motor
signals away from the cns
MOVEMENT OF MATERIALS
WITHIN AXON
• The movement of materials within
the axon is necessary for its normal
function, but it also provides a way
 for infectious agents and harmful
substances to be transported from
the periphery to the cns.
• For example, rabies and herpes
viruses can enter damaged axons in
the skin and be transported within
the axons to the cns.
STRUCTURAL TYPES OF
NEURONS
• Multipolar neurons have many
dendrites and a single axon.
• Most of the neurons within the cns
and nearly all motor neurons are
multipolar.
• Bipolar neurons have two
processes: one dendrite and one
axon.
• Bipolar neurons are located in some
sensory organs, such as in the retina
of the eye and in the nasal cavity
• Pseudo-unipolar neurons have a
single process extending from the
cell body, which divides into two
processes as short distance from the
cell body.
• One process extends to the
periphery, and the other extends to
the cns.
• The two extensions function as a
single axon with small, dendrite-like
sensory receptors at the periphery.
GLIAL CELLS
• Glial cells are the supportive cells of
the cns and pns.
• Astrocytes serve as the major
supporting cells in the cns.
• Astrocytes can stimulate or inhibit
the signaling activity of nearby
neurons and form the blood-brain
barrier.
• Ciliated ependymal cells lining the
ventricles of the brain and the central
canal of the spinal cord help move
cerebrospinal fluid.
• Ependymal cells on the surface of
the choroid plexus secrete
cerebrospinal fluid.
• Microglial cells act in an immune
function in the cns by removing
bacteria and cell debris.
• Oligodendrocytes provide myelin to
neurons in the cns.
• Schwann cells provide myelin to
neurons in the pns.
MYELIN SHEATH
• Myelin sheaths are specialized
layers that wrap around the axons of
some neurons, those neurons are
termed, myelinated.
• Myelin is an excellent insulator that
prevents almost all ion movement
across the cell membrane.
• Gaps in the myelin sheath, called
nodes of ranvier, occur about every
millimeter. Ion movement can occur
at the nodes of ranvier.
UNMYELINATED NEURONS
• Unmyelinated axons lack the myelin
sheaths.
• A typical small nerve, which consists
of axons of multiple neurons,
usually contains more unmyelinated
axons than myelinated axons.
ORGANIZATION OF NERVOUS
TISSUE
• Nervous tissue exists as gray matter
and white matter.
• Gray matter consists of groups of
neuron cell bodies and their
dendrites, where there is very little
myelin.
 • White matter consists of bundles of
parallel axons with their myelin
sheaths, which are whitish in color.
MEMBRANE POTENTIALS
• Resting membrane potentials and
action potentials occur in neurons.
• These potentials are mainly due to
differences in concentrations of ions
across the membrane, membrane
channels, and the sodium- potassium
pump.
• Membrane channels include leak
channels and gated channels.
LEAK MEMBRANE CHANNELS
• Leak channels are always open are
and ions can “leak” across the
membrane down their concentration
gradient.
• There are 50 to 100 times more k+
leak channels than na+ leak
channels, the resting membrane has
much greater permeability to k+
than to na+; therefore, the k+ leak
channels have the greatest
contribution to the resting membrane
potential.
GATED MEMBRANE
CHANNELS
• Gated channels are closed until
opened by specific signals.
• Chemically gated channels are
opened by neurotransmitters or other
chemicals, whereas voltage-gated
channels are opened by a change in
membrane potential.
SODIUM-POTASSIUM PUMP
• The sodium-potassium pump
compensates for the constant
leakage of ions through leak
channels.
• The sodium-potassium pump is
required to maintain the greater
concentration of na+ outside the cell
membrane and k+ inside.
• It is estimated that the sodium-
potassium pump consumes 25% of
all the atp in a typical cell and 70%
of the atp in a neuron
RESTING MEMBRANE
POTENTIAL
• The resting membrane potential
exists because of:
• The concentration of k+ being higher
on the inside of the cell membrane
and the concentration of na+ being
higher on the outside
• The presence of many negatively
charged molecules, such as proteins,
inside the cell that are too large to
exit the cell
• The presence of leak protein
channels in the membrane that are
more permeable to k+ than it is to
na+
ACTION POTENTIAL
• Action potentials allow conductivity
along nerve or muscle membrane .
• The channels responsible for the
action potential are voltage-gated
na+ and k+ channels, which are
closed during rest.
• When a stimulus is applied to the
nerve cell, following
neurotransmitter activation of
chemically gated channels, na+
channels open very briefly, and na+
diffuses quickly into the cell.
• The movement of na+, which is
called a local current, causes the
inside of the cell membrane to
become positive, a change called
depolarization
 • If depolarization is not strong
enough, the na+ channels close
again, and the local potential
disappears without being conducted
along the nerve cell membrane.
• If depolarization is large enough, na+
enters the cell so that the local
potential reaches a threshold value.
• This threshold depolarization causes
voltage- gated na+ channels to open,
generally at the axon hillock.
• As more na+ enters the cell,
depolarization continues at a much
faster pace, causing a brief reversal
of charge – the inside of the cell
membrane becomes positive relative
to the outside of the cell membrane.
• The charge reversal causes na+
channels to close and na+ then stops
entering the cell.
• During this time, more k+ channels
are opening and k+ leaves the cell,
resulting in repolarization.
• At the end of repolarization, the
charge on the cell membrane briefly
becomes more negative than the
resting membrane potential; this
condition is called hyperpolarization
and occurs briefly.
• Action potentials occur in an all-or-
none fashion
• The sodium-potassium pump assists
in restoring the resting membrane
potential.
UNMYELINATED AXON
ACTION POTENTIALS
• Action potentials are conducted
slowly in unmyelinated axons and
more rapidly in myelinated axons.
• Action potentials along
unmyelinated axons occur along the
entire membrane.
MYELINATED AXON ACTION
POTENTIALS
• Action potentials on myelinated
axons occur in a jumping pattern at
the nodes of ranvier.
• This type of action potential
conduction is called saltatory
conduction.
AXON CONDUCTION SPEED
• The speed of action potential
conduction varies widely, even
among myelinated axons; it is based
on the diameter of axon fibers.
• Medium-diameter, lightly myelinated
axons, characteristic of autonomic
neurons, conduct action potentials at
the rate of about 3 to 15 meters per
second (m/s).
• Large-diameter, heavily myelinated
axons conduct action potentials at
the rate of 15 to 120 m/s.
SYNAPSE
• An action potential reaching the
presynaptic terminal causes voltage-
gated ca2+ channels to open, and
ca2+ moves into the cell.
• This influx of ca2+ causes the
release of neurotransmitters by
exocytosis from the presynaptic
terminal.
• The neurotransmitters diffuse across
the synaptic cleft and bind to
specific receptor molecules on the
postsynaptic membrane.
 • The binding of neurotransmitters to
these membrane receptors causes
chemically gated channels for na+,
k+, or cl− to open or close in the
postsynaptic membrane.
• The response may be either
stimulation or inhibition of an action
potential in the postsynaptic cell.
• If na+ channels open, the
postsynaptic cell becomes
depolarized, and an action potential
will result if threshold is reached.
• If k+ or cl− channels open, the inside
of the postsynaptic cell tends to
become more negative, or
hyperpolarized, and an action
potential is inhibited from occurring.
• There are many neurotransmitters,
with the best known being
acetylcholine and norepinephrine.
• Neurotransmitters do not normally
remain in the synaptic cleft
indefinitely, thus their effects are
short duration.
• An enzyme called
acetylcholinesterase breaks down
the acetylcholine.
• Norepinephrine is either actively
transported back into the presynaptic
terminal or broken down by
enzymes.
REFLEX
• A reflex is an involuntary reaction in
response to a stimulus applied to the
periphery and transmitted to the cns.
• Most reflexes occur in the spinal
cord or brainstem rather than in the
higher brain centers.
• A reflex arc is the neuronal pathway
by which a reflex occurs and has
five basic components.
NEURONAL PATHWAY
(CONVERGING)
• The cns has simple to complex
neuronal pathways.
• In convergent pathways many
neurons converge and synapse with
a smaller number of neurons.
Convergence allows different parts
of the nervous system to activate or
inhibit the activity of neurons.
NEURONAL PATHWAY
(DIVERGING)
• In divergent pathways, a smaller
number of presynaptic neurons
synapse with a larger number of
postsynaptic neurons to allow
information transmitted in one
neuronal pathway to diverge into two
or more pathways.
• Diverging pathways allow one part
of the nervous system to affect more
than one other part of the nervous
• Summation
• Depolarizations produced in
postsynaptic membranes are graded
potentials.
• A single presynaptic action potential
usually does not cause a sufficiently
large postsynaptic local potential to
reach threshold and produce an
action potential in the target cell.
• Many presynaptic action potentials
are needed in a process called
summation.
• Summation of signals in neuronal
pathways allows integration of
multiple subthreshold local
potentials.
• Summation of the local potentials
can bring the membrane potential to
 threshold and trigger an action
potential.
TWO TYPES OF SUMMATION
• Spatial summation occurs when
multiple action potentials arrive
simultaneously at two different
presynaptic terminals that synapse
with the same postsynaptic neuron.
• In the postsynaptic neuron, each
action potential causes a
depolarizing graded potential that
undergoes summation at the trigger
zone. If the summated
depolarization reaches threshold, an
action potential is produced.
• Temporal summation results when
two or more action potentials arrive
in very close succession at a single
presynaptic terminal.
• The first action potential causes a
depolarizing graded potential in the
postsynaptic membrane that remains
for a few milliseconds before it
disappears, although its magnitude
decreases through time.
• Temporal summation results when
another action potential initiates
another graded depolarization before
the depolarization caused by the
previous action potential returns to
its resting value.
MYASTHENIA GRAVIS
• Myasthenia gravis (mg) is a chronic
autoimmune disorder affecting the
neuromuscular transmission of
impulses in the voluntary muscles of
the body.
• Mg is characterized by fluctuating
weakness increased by exertion.
Weakness increases during the day
and improves with rest.
MYASTHENIA GRAVIS
PATHOPHYSIOLOGY
• Autoantibodies directed at the
acetylcholine receptor sites impair
transmission of impulses across the
terminal junction.
• Fewer receptors are available for
stimulation, resulting in voluntary
muscle weakness that escalates with
continued activity.
• These antibodies are found in 80% to
90% of the people with myasthenia
gravis.
• Eighty percent of persons with
myasthenia gravis have either thymic
hyperplasia or a thymic tumor (roos,
1999), and the thymus gland is
believed to be the site of antibody
production.
CLINICAL MANIFESTATIONS
• Extreme muscular weakness and
easy fatigability
• Vision disturbances—diplopia and
ptosis from ocular weakness.
• Facial muscle weakness causes a
masklike facial expression.
• Dysarthria and dysphagia from
weakness of laryngeal and
pharyngeal muscles.
• Proximal limb weakness, with
specific weakness in the small
muscles of the hands.
• Respiratory muscle weakness can be
life- threatening.
TREATMENT
• Oral anticholinesterase drugs, such
as neostigmine (prostigmin) and
pyridostigmine (mestinon, regonol),
are first-line treatments for mild mg,
enhancing neuromuscular
.transmission.
• Immunosuppressive drugs, such as
prednisone, are the mainstay of
 treatment when weakness is not • Difficulty with swallowing, speech,
adequately controlled by and chewing due to cranial nerve
anticholinergic medication. involvement.

• Thymectomy is indicated for patients • Autonomic dysfunction (increased

with tumor or hyperplasia of the heart rate and postural hypotension).
thymus gland.
• Decreased vital capacity, depth of
GUILLAIN-BARRÉ SYNDROME respirations, and breath sounds.

• Guillain-barré syndrome is an TREATMENT

autoimmune attack of the peripheral
nerve myelin.
• The result is acute, rapid segmental
demyelination of peripheral nerves
and some cranial nerves, producing
ascending weakness.
GUILLAIN-BARRÉ SYNDROME
PATHOPHYSIOLOGY
• Immune system destroys the
myelin sheath surrounding
peripheral nerve axons.
• Plasmapheresis produces temporary
reduction of circulating antibodies to
reduce the severity and duration of
the gbs episode.
• High-dose immunoglobulin therapy
is used to reduce the severity of the
episode.
• Cardiac and respiratory treatment.

• The best-accepted theory is that an

infectious organism contains an
amino acid that mimics the
peripheral nerve myelin protein. The
immune system cannot distinguish
between the two proteins and attacks
and destroys peripheral nerve
myelin.

• With the autoimmune attack there is

an influx of macrophages and other
immune- mediated agents that attack
myelin, cause inflammation and
destruction, and leave the axon
unable to support nerve conduction.

CLINICAL MANIFESTATIONS
• Paresthesias and, possibly,
dysesthesia.

• Acute onset of symmetric

progressive muscle weakness; most
often beginning in the legs and
ascending to involve the trunk,
upper extremities, and facial
muscles. Paralysis may develop.
NERVOUS SYSTEM PART 2
CENTRAN NERVOUS
SYSTEM ANATOMY
THE BRAIN
• The brain lies in the cranial cavity
and weighs between 1450–1600 g. It
receives 15% of the cardiac output
and has a system of autoregulation
ensuring the blood supply is
constant despite positional changes.

CEREBRUM
• The cerebrum accounts for the
largest portion of total brain weight,
which is about 1200 g in females
and 1400 g in males. Brain size is
related to body size; larger brains
are associated with larger bodies,
not with greater intelligence.

• The cerebrum houses the nerve

center that controls sensory and
motor activities and intelligence.

• The cerebrum is divided into left and

right hemispheres by a longitudinal
fissure.

• The most conspicuous features on

the surface of each hemisphere are
numerous folds called gyri, which
 greatly increase the surface area of
the cortex.
• The grooves between the gyri are
called sulci.
• The central sulcus, which extends
across the lateral surface of the
cerebrum from superior to inferior,
is located about midway along the
length of the brain.
• Anterior to the central sulcus is the
precentral gyrus, which is the
primary motor cortex.
• Posterior to the central sulcus
is the postcentral gyrus, which is the
primary somatic sensory cortex.
CEREBRAL CORTEX
• The cerebrum is covered by a
continuous layer of gray matter that
wraps around either side of the
forebrain—the cerebral cortex.
This thin, extensive region of
wrinkled gray matter is responsible
for the higher functions of the
nervous system.
CORPUS COLLOSUM
• White matter deep within the
cerebrum provides the major
pathway for communication
between the two hemispheres of the
cerebral cortex
DIFFERENT FUNCTIONAL
AREAS OF THE CEREBRAL
CORTEX ARE DIVIDED INTO
LOBES
• Frontal lobe is important in
voluntary motor function,
motivation, aggression, the sense of
smell, and mood.
• The anterior region, called the
prefrontal cortex, is involved in
personality and decision making.
• Parietal lobe is the main sensory
receptive area for the sense of touch
in the somatosensory cortex which is
just posterior to the central sulcus in
the postcentral gyru.
• The frontal and parietal lobes are
separated by the central sulcus.
• Occipital lobe functions in receiving
and integrating visual input and is
not distinctly separate from the other
lobes.
• Temporal lobe receives and
evaluates input for smell and
hearing and plays an important role
in memory.
• Its anterior and inferior portions,
called the “psychic cortex,” are
associated with such brain functions
as abstract thought and judgment.
INSULA
• The temporal lobe is separated from
the rest of the cerebrum by a lateral
fissure, and deep within the fissure
is the insula. The insula receives and
evaluates taste information and is
often referred to as a fifth lobe.
CEREBELLUM
• The cerebellum is attached to the
brainstem posterior to the pons. It
lies behind and below the cerebrum.
• Like the cerebrum, it has an outer
cortex of gray matter and an inner
core of white matter.
• The cerebellum functions to maintain
muscle tone, coordinate muscle
movement, and control balance.
DIENCEPHALON
• The diencephalon is the part of the
brain between the brainstem and the
cerebrum. Its main components are
the thalamus, subthalamus,
epithalamus, and hypothalamus.
THALAMUS
• The thalamus is the largest part of
the diencephalon, constituting about
four-fifths of its weight. It consists
of a cluster of nuclei shaped
somewhat like a yo-yo.
• Except for the olfactory neurons, all
sensory neurons that project to the
cerebrum first synapse in the
thalamus.
• Thalamic neurons then send
projections to the appropriate areas
of the cerebral cortex where sensory
input is localized.
PARTS OF THE THALAMUS
• Axons carrying auditory information
synapse in the medial geniculate
nucleus of the thalamus.
• Axons carrying visual information
synapse in the lateral geniculate
nucleus.
• Most other sensory impulses synapse
in the ventral posterior nucleus.
• Axons originating in the ventral
posterior nucleus project to the
dorsal tier of nuclei, which register
pain .
• The ventral anterior nucleus and the
ventral lateral nucleus are involved
with motor functions,
communicating among the basal
nuclei, the cerebellum, and the motor
cortex.
• The thalamus also influences mood
and actions associated with strong
emotions, such as fear and rage.
• The anterior and medial nuclei are
connected to the limbic system and
to the prefrontalcortex. These nuclei
are involved in mood modification.
• The lateral dorsal nuclei, which are
connected to other thalamic nuclei
and to the cerebral cortex, are
involved in regulating emotions.
• The lateral posterior nuclei and the
pulvinar also have connections to
other thalamic nuclei and are
involved in sensory integration.
SUBTHALAMUS
• The subthalamus is a small area
immediately inferior to the thalamus
, it contains several ascending and
descending tracts and the
subthalamic nuclei.
• The subthalamic nuclei are
associated with the basal nuclei and
are involved in controlling motor
functions.
EPITHALAMUS
• The epithalamus is a small area
superior and posterior to the
thalamus.
• The habenula is influenced by the
sense of smell and is involved in
emotional and visceral responses to
odors.
• The pineal gland, or pineal body. Its
functions in humans are not fully
understood, researchers do know that
it produces and regulates some
hormones, including melatonin.
Melatonin is best known for the role
it plays in regulating sleep patterns.
HYPOTHALAMUS
 • Inferior and slightly anterior to the
thalamus is the hypothalamus, the
other major region of the
diencephalon.
• The hypothalamus is the executive
region in charge of the autonomic
nervous system and the endocrine
system through its regulation of the
anterior pituitary gland.
• Contains the centers for sexual
reflexes; body temperature; water,
carbohydrate, and fat metabolism;
and emotions that affect the
heartbeat and blood pressure.
• Other parts of the hypothalamus are
involved in memory and emotion as
part of the limbic system.
BRAINSTEM
• The brainstem consists of three parts:
the medulla oblongata, pons, and
midbrain.
• The brainstem is responsible for
many essential functions. Damage to
small areas often causes death,
because many reflexes essential for
survival are integrated in the
brainstem, whereas relatively large
areas of the cerebrum or cerebellum
may be damaged without life-
threatening consequences.
MEDULLA OBLONGATA
• The medulla oblongata, often called
the medulla, is about 3 cm long. It is
the most inferior part of the
brainstem and is continuous
inferiorly with the spinal cord.
• The medulla oblongata contains
sensory and motor tracts, cranial
nerve nuclei.
• Two prominent enlargements on the
anterior surface of the medulla
oblongata are called pyramids
because they are broader near the
pons and taper toward the spinal cord
• The pyramids are formed by the
large descending tracts involved in
the conscious control of skeletal
muscles. Near their inferior ends,
most of the fibers of the descending
tracts cross to the opposite side, or
decussate.
• Two rounded, oval structures, called
olives, protrude from the anterior
surface of the medulla oblongata
just lateral to the superior ends of
the pyramids.
• The olives are nuclei involved in
functions such as balance,
coordination, and modulation of
sound from the inner ear.
• The medulla oblongata is a relay
station for sensory nerves going to
the cerebrum.
• The medulla contains autonomic
centers such as the cardiac center,
the respiratory center, the vasomotor
center and the coughing, sneezing
and vomiting center.
PONS
• The part of the brainstem just
superior to the medulla oblongata is
the pons.
• The pons contains ascending and
descending tracts and several nuclei.
The pontine nuclei, located in the
anterior portion of the pons, relay
information from the cerebrum to
the cerebellum.
• Important pontine areas are the
pontine sleep center, which initiates
rapid eye movement sleep and the
pontine respiratory center, which
works with the respiratory centers in
the medulla oblongata to help
control respiratory movements.
MIDBRAIN
• The midbrain, or mesencephalon, is
the smallest region of the brainstem.
• It is located just superior to the pons
and contains the nuclei of cranial
nerves iii (oculomotor), iv
(trochlear), and v (trigeminal).
• The midbrain is separated into the
tectum and tegmentum.
• The tectum is composed of four
bumps known as the colliculi.
• Inferior colliculus is part of the
auditory brain stem pathway.
• The superior colliculus combines
sensory information about visual
space, auditory space, and
somatosensory space.
• Activity in the superior colliculus is
related to orienting the eyes to a
sound or touch stimulus.
• The tegmentum contains the nuclei
that receive and send information
through the cranial nerves, as well as
regions that regulate important
functions such as those of the
cardiovascular and respiratory
systems.
LIMBIC SYSTEM
• Parts of the cerebrum and
diencephalon are grouped together
under the title limbic system .
• The limbic system plays a central
role in basic survival functions, such
as memory, reproduction, and
nutrition. It is also involved in
interpreting sensory input and
emotions in general.
MENINGES
• Meninges is a connective tissue that
covers the outer surface of the cns.
• The meninges consist of three
connective tissue layers; dura,
arachnoid and pia matters.
DURA MATER
• The dura mater is a tough outer
covering. It encloses the entire cns
and the major blood vessels that
enter the cranium and vertebral
cavity.
• Within the cranial cavity, the dura
mater tightly adheres to the cranial
bones.
• The dura mater within the cranial
cavity consists of two layers. The
outer layer, the periosteal dura, is
the inner periosteum of the cranial
bones. The inner layer, the
meningeal dura.
• Within the vertebral canal, the dura
mater is distinctly separate from the
vertebrae, forming an epidural
space.
ARACHNOID MATER
• Arachnoid matter is the middle layer
of the meninges. The space between
this membrane and the dura mater is
the subdural space; it contains only a
very small amount of serous fluid.
• The arachnoid defines a sac-like
trabeculae enclosure around the cns.
• The trabeculae are found in the
subarachnoid space, which is filled
with circulating csf.
PIA MATER
• Pia mater a thin fibrous, fluid
impermeable membrane that covers
the outer surface of the cns.
VENTRICLES
• The ventricular system is a set of
communicating cavities within the
brain.
 • These structures are responsible for
the production, transport and
removal of cerebrospinal fluid,
which bathes the central nervous
system.
• The interior of the tube is lined with
a single layer of epithelial cells
called ependymal cells.
• Each cerebral hemisphere contains a
relatively large cavity, the lateral
ventricle
• The lateral ventricles are separated
from each other by thin septa
pellucida.
• The third ventricle is smaller midline
cavity, located in the center of the
diencephalon between the two
halves of the thalamus. The two
lateral ventricles communicate with
the third ventricle through two
interventricular foramina.
• The fourth ventricle is in the inferior
part of the pontine region and the
superior region of the medulla
oblongata at the base of the
cerebellum.
• The third ventricle communicates
with the fourth ventricle through a
narrow canal, the cerebral aqueduct,
which passes through the midbrain.
• The fourth ventricle is continuous
with the central canal of the spinal
cord, which extends nearly the full
length of the cord.
CEREBROSPINAL FLUID
• Cerebrospinal fluid is produced by
modified ependymal cells of the
choroid plexus found in all
components of the ventricular
system.
• Csf fills the ventricles, the
subarachnoid space of the brain and
spinal cord, and the central canal of
the spinal cord. Approximately 23
ml of fluid fills the ventricles, and
117 ml fills the sub arachnoid space
• Primary function of csf is to cushion
the brain within the skull
• Csf also circulates nutrients and
chemicals filtered from the blood
and removes waste products from the
brain.
BLOOD BRAIN BARRIER
• The bbb is semi-permeable, it allows
some materials to cross, but prevents
others from crossing.
• Glial cells (astrocytes) form a layer
around brain blood vessels and may
be important in the development of
the bbb.
FUNCTIONS OF BBB
• Bbb protects brain cells from
harmful substances and pathogens by
preventing passage of many
substances from the blood into the
brain tissue.
• A few water soluble substances, such
as glucose, cross the bbb by active
transport.
• Protein and most antibiotics do not
cross the bbb to get into the brain
tissue.
• Lipid soluble substances such as
oxygen, carbon dioxide, alcohol and
most anaesthetic drugs cross the bbb
easily.
• The bbb can be broken down by
hypertension
• Exposure to microwaves, exposure to
radiation, infection and injury to the
brain such as inflammation and
ischemia can all open the bbb.
• The bbb is not considered to affect
the movement of inflammatory cells
 into the cns; activated lymphocytes
can enter the normal cns
HEAD INJURY
• Head injury, also know as traumatic
brain injury (tbi) is the disruption of
normal brain function due to
trauma-related injury.
• Tbi produces compromised
neurologic function, resulting in
focal or diffuse symptoms.
• Falls are the most common etiology
of injury, followed by motor vehicle
accidents
• Head injuries are classified as open
or closed.
• Closed injuries are more common
and usually result from the head
striking a hard surface or an object
striking the head.
• Such injuries may cause brain trauma
—either coup, occurring at the site
of impact, or contrecoup, occurring
on the opposite side of the brain
from the impact as a result of the
brain moving within the skull.
• Concussion is the most common
traumatic brain injury , characterized
by immediate, but transient,
impairment of neural function, such
as loss of consciousness or blurred
vision. No structural injury noted on
radiographics.
• A concussion is most often caused
by a sudden direct blow or bump to
the head.
• Traumatic brain injury may be
diffuse or focal.
• Diffuse brain injury usually results
from shaking, as when a child is
shaken or when a person is thrown
about in an automobile accident,
such injury is not localized to one
focal point but involves damage to
many small vessels and nerves,
especially around the brainstem.
• Focal traumatic brain injury may
involve cortical contusions, caused
by direct impact to the brain, or
hemorrhages in or around the brain.
Contusions are usually superficial
and involve only the gyri.
• Hemorrhagic brain injury is
characterized by bleeding outside
the dura ( epidural), between the
dura and the brain (subdural), or
within the brain (intracerebral). A
hemorrhage, which is bleeding,
results in a hematoma.
• Epidural hematoma—blood between
the inner table of the skull and dura.
Frequently associated with injury or
laceration of the middle meningeal
artery secondary to a temporal bone
fracture. Arterial bleed is commonly
associated with a lucid interval,
followed by unresponsiveness.
• Subdural hematoma—blood between
the dura and arachnoid caused by
venous bleeding; commonly
associated with contusion, or
intracerebral hematoma.
• Intracerebral hematoma—bleeding
into the brain tissue commonly
associated with edema. Often
associated with cocntusions. They
involve damage to small vessels
within the brain itself and are most
common in the frontal and temporal
lobes.
• Open head trauma involves a fracture
or hole in the skull, which exposes
the contents of the cranial cavity to
the exterior.
• In skull fractures in which the
meninges are torn, csf may leak
from the nose if the fracture is in the
 frontal area or from the ear if the
fracture is in the temporal area.
• Leakage of csf indicates serious
mechanical damage to the head and
presents a risk for meningitis
because bacteria may pass from the
nose or ear through the tear and into
the meninges.
HYDROCEPHALUS
• Hydrocephalus is a condition where
there is an abnormal build up of csf
in the ventricles of the brain.
• The cerebral aqueduct may be
blocked at the time of birth or may
become blocked later in life because
of a tumor growing in the brainstem.
• If the apertures of the fourth
ventricle or the cerebral aqueduct
are blocked, csf can accumulate
within the ventricles, resulting in a
condition called internal
hydrocephalus (noncommunicating
hydrocephalus).
• Communicating or external
hydrocephalus—csf circulates
through the ventricular system into
the subarachnoid space with no
obstruction. Can be due to a
subarachnoid hemorrhage block the
return of csf to the circulation.
• Most often this occurs at the
arachnoid villi. Examples of
communicating hydrocephalus
include post- meningitic or post-
hemorrhagic hydrocephalus.
• In this condition, pressure is applied
to the brain externally, compressing
neural tissues and causing brain
damage. The condition usually
resolves without treatment.
HYDROCEPHALUS
PATHOPHYSIOLOGY
• The production of csf continues,
even when the passages that
normally allow it to exit the brain
are blocked.
• Fluid builds inside the brain, causing
pressure, which compresses the
nervous tissue and dilates the
ventricles.
• Compression of the nervous tissue
usually results in irreversible brain
damage.
• If the skull bones are not completely
ossified when the hydrocephalus
occurs, the pressure may also
severely enlarge the head.
INTERNAL HYDROCEPHALUS
TREATMENT
• Surgical procedures, including direct
operation on the lesion causing the
obstruction, such as a tumor.
• Ventriculoperitoneal (vp) shunt
between the brain ventricles and the
abdominal cavity to diverts csf from
a lateral ventricle or the spinal
subarachnoid space to the peritoneal
cavity.
BLOOD CIRCULATION TO THE
BRAIN
• Four major arteries—two vertebral
and two carotid—supply the brain
with oxygenated blood.
• Vertebral convergence: the two
vertebral arteries (branches of the
subclavians) converge to become the
basilar artery. The basilar artery
supplies blood to the posterior brain.
• The common carotids branch into the
two internal carotids, which divide
further to supply blood to the
anterior brain and the middle brain.
• These arteries interconnect through
the circle of willis, an anastomosis
 at the base of the brain. The circle of
willis ensures that blood continually
circulates to the brain despite
interruption of any of the brain’s
major vessels.
CEREBROVASCULAR
ACCIDENT (CVA)
• Cerebrovascular accident (cva),
stroke or brain attack is the onset
and persistence of neurologic
dysfunction lasting longer than 24
hours and resulting from disruption
of blood supply to the brain and
indicates infarction rather than
ischemia.
• Strokes are classified as ischemic
(more than 70% of strokes) or
hemorrhagic (associated with greater
morbidity and mortality)
ISCHEMIC STROKE
PATHOPHYSIOLOGY
• Partial or complete occlusion of a
cerebral blood flow to an area of the
brain due to:
• Thrombus —due to arteriosclerotic
plaque in a cerebral artery.
• Embolus—a moving clot of cardiac
origin or from a carotid artery that
travels quickly to the brain and
lodges in a small artery; occurs
suddenly with immediate maximum
deficits.
• Area of brain affected is related to
the vascular territory that was
occluded. Subtle decrease in blood
flow may allow brain cells to
maintain minimal function, but as
blood flow decreases, focal areas of
ischemia occur, followed by
infarction to the vascular territory.
• An area of injury includes edema,
tissue breakdown, and small arterial
vessel damage. The small arterial
vessel damage poses a risk of
hemorrhage. The larger the area of
infarction, the greater the risk of
hemorrhagic conversion.
• Ischemic strokes are not activity
dependent; may occur at rest.
HEMORRHAGIC STROKE
PATHOPHYSIOLOGY
• Leakage of blood from a blood
vessel and hemorrhage into brain
tissue, causing edema, compression
of brain tissue, and spasm of
adjacent blood vessels. May occur in
the epidural, beneath the dura
subdural, in the sas, or intracerebral.
• Causal mechanisms include:
 Increased pressure due to
hypertension.
 Head trauma causing dissection or
rupture orvessel.
 Deterioration of vessel wall from
chronic hypertension or diabetes
mellitus.
CLINICAL MANIFESTATIONS
• Headache may be a sign of
impending cerebral hemorrhage or
infarction; however, it is not always
present.
• Paresthesia, paresis, or plegia on one
side of the body, drooping on one
side of the face.
• Loss of balance
• Dysphagia
• Aphasia
• Hemianopsia or double vision
DIAGNOSTIC EVALUATION
• Mri/ct scan—to determine cause and
location of stroke and type of stroke,
ischemic versus hemorrhagic
MONROE KELLY DOCTRINE
• The cranial compartment is inelastic
and the volume inside the cranium is
fixed. It only contains csf, brain
tissue and blood.
• Increase in volume in any of the
brain components will cause an
increased icp.
CRANIAL NERVES
• Cranial nerves transmit and relay
information to the brain analogous
to the spinal nerves.
• Cranial nerve may have one or more
of three functions: (1) sensory, (2)
somatic motor, and (3)
parasympathetic.
SPINAL CORD
• The spinal cord is a cylindrical
structure in the vertebral canal that
extends from the foramen magnum
at the base of the skull to the level of
the second lumbar vertebra.
• The spinal cord is the major
communication link between the
brain and the pns inferior to the head.
It integrates incoming information
and produces responses through
reflex mechanisms.
• The spinal cord is composed of
cervical, thoracic, lumbar, and sacral
segments, named according to the
portion of the vertebral column from
which their nerves enter and exit.
• The spinal cord gives rise to 31 pairs
of spinal nerves, which exit the
vertebral column through
intervertebral and sacral foramina.
• The spinal cord is larger in diameter
at its superior end, and it gradually
decreases in diameter toward its
inferior end.
• The cervical enlargement in the
inferior cervical region corresponds
to the location where nerve fibers
that supply the upper limbs enter and
leave the spinal cord .
• The lumbosacral enlargement in the
inferior thoracic, lumbar, and
superior sacral regions is the site
where the nerve fibers supplying the
lower limbs enter or leave the spinal
cord.
• Immediately inferior to the
lumbosacral enlargement, the spinal
cord tapers to form a conelike region
called the conus medullaris.
• The nerves supplying the lower
limbs and other inferior structures of
the body arise from the lumbar and
sacral regions.
• The numerous roots of spinal nerves
extending inferiorly from the
lumbosacral enlargement and conus
medullaris resemble a horse’s tail
and are called the cauda equina.
MENINGES OF THE SPINAL
CORD
• The spinal cord and brain are
surrounded by connective tissue
membranes called meninges.
• The most superficial and thickest
membrane is the dura mater.
• The spinal dura mater is continuous
with the dura mater surrounding the
brain and the connective tissue
surrounding the spinal nerves.
• The dura mater around the spinal
cord is separated from the
periosteum of the vertebral canal by
the epidural space
• The next deeper meningeal
membrane is a very thin, arachnoid
mater. The space between this
membrane and the dura mater is the
 subdural space; it contains only a
very small amount of serous fluid.
• The third, deepest meningeal layer,
the pia mater is bound very tightly
to the surface of the spinal cord.
Holding the spinal cord in place
within the thecal sac are the
denticulate ligaments and the filum
terminale
• Between the arachnoid mater and the
pia mater is the subarachnoid space,
which contains weblike strands of
the arachnoid mater, blood vessels,
and cerebrospinal
DENTICULATE LIGAMENTS
• Denticulate ligaments are connective
tissue septa extending from the
lateral sides of the spinal cord to the
dura mater. The denticulate
ligaments attach to the dura mater
by toothlike processes between the
exits of the cervical and thoracic
spinal nerves. The denticulate
ligaments limit the lateral movement
of the spinal cord
FILUM TERMINALE
• The filum terminale is a connective
tissue strand that anchors the conus
medullaris and the thecal sac to the
first coccygeal vertebra, limiting
their superior movement.
INTRODUCTION OF NEEDLES
INTO THE SUBARACHNOID
SPACE
• Spinal anesthesia, or spinal block,
drugs that block action potential
transmission are introduced into the
subarachnoid space to prevent pain
sensations in the lower half of the
body.
• This procedures involve inserting a
needle into the subarachnoid space
at either the l3/l4 or l4/l5 level. The
needle does not puncture the spinal
cord because the cord extends only
approximately to the second lumbar
vertebra of the vertebral column, but
the subarachnoid space extends to
level s2 of the vertebral column.
EPIDURAL VS SPINAL
ANESTHESIA
• Epidural anesthesia is the injection of
drug into the epidural space around
the spinal cord.
• In spinal anesthesia, the drugs are
delivered directly to the csf, so the
anesthesia is generally stronger and
takes effect faster than epidural
anesthesia.
• With epidural anesthesia, the needle
does not penetrate the dura mater, so
the drugs must first diffuse into the
csf. However, an advantage is that
the drugs can be readministered via
a catheter (flexible tube) to maintain
longer anesthesia.
LUMBAR PUNCTURE
• Lumbar puncture, or spinal tap, csf is
removed from the subarachnoid
space in order to examine it for
infectious agents (meningitis) or for
the presence of blood (hemorrhage)
or to measure the cs pressure.
CROSS SECTION OF THE
SPINAL CORD
• A cross section reveals that the
spinal cord consists of a superficial
white portion and a deep gray
portion. The white matter consists of
myelinated axons, which form nerve
tracts, and the gray matter consists
of neuron cell bodies, dendrites, and
axons.
• An anterior median fissure and a
posterior median sulcus are deep
 clefts partially separating the two
halves of the cord.
• The white matter in each half of the
spinal cord is organized into three
columns, or funiculi, called the
ventral (anterior), dorsal (posterior),
and lateral columns. Each column of
the spinal cord is subdivided into
tracts, or fasciculi, also referred to as
pathways.
• A collection of axons inside the cns
is called a tract, whereas outside the
cns it is called a nerve.
• Tracts have different myelination
than nerve sand lack the extensive
connective tissue of nerves.
• Individual axons ascending to the
brain or descending from the brain
are usually grouped together within
the tracts . Axons within a given
tract carry basically the same type of
information, although they may
overlap to some extent.
• The central gray matter is organized
into horns. Each half of the central
gray matter of the spinal cord
consists of a relatively thin posterior
(dorsal) horn and a larger anterior
(ventral) horn. Small lateral horns
exist in the levels of the cord
associated with the autonomic
nervous system.
• The two halves of the spinal cord are
connected by gray and white
commissures. The gray and white
commissures contain axons that
cross from one side of the spinal cord
to the other.
SENSORY PATHWAYS
• Sensory impulses travel via the
afferent (sensory, or ascending)
neural pathways to the sensory
cortex in the parietal lobe of the
brain. This is where the impulses are
interpreted. These impulses use two
major pathways: the dorsal horn and
the ganglia.
• Pain and temperature sensations
enter the spinal cord through the
dorsal horn. After immediately
crossing over to the opposite side of
the cord, these impulses then travel
to the thalamus via the spinothalamic
tract.
• Touch, pressure, vibration sensations
enter the cord via relay stations
called ganglia. Ganglia are knotlike
masses of nerve cell bodies on the
dorsal roots of spinal nerves.
• Impulses travel up the cord in the
dorsal column to the medulla, where
they cross to the opposite side and
enter the thalamus. The thalamus
relays all incoming sensory impulses
(except olfactory impulses) to the
sensory cortex for interpretation.
MOTOR PATHWAYS
• Motor impulses travel from the brain
to the muscles via the efferent
(motor, or descending) neural
pathways. Motor impulses originate
in the motor cortex of the frontal
lobe and reach the lower motor
neurons of the peripheral nervous
system via upper motor neurons.
• The pyramidal system (corticospinal
tract) is responsible for fine, skilled
movements of skeletal muscle.
Impulses in this system travel from
the motor cortex through the internal
capsule to the medulla. At the
medulla, they cross to the opposite
side and continue down the spinal
cord.
• The extrapyramidal system
(extracorticospinal tract) controls
gross motor movements.
 • Impulses originate in the premotor
area of the frontal lobes and travel to
the pons. At the pons, the impulses
cross to the opposite side.
• Then the impulses travel down the
spinal cord to the anterior horn,
where they’re relayed to the lower
motor neurons. These neurons, in
turn, carry the impulses to the
muscles
A reflex is an automatic response to a
stimulus produced by a reflex arc. It
occurs without conscious thought
DEEP TENDON REFLEXES
• Deep tendon reflexes involuntary
contractions of a muscle after brief
stretching caused by tendon
percussion.
• Deep tendon reflexes include reflex
responses of the biceps, triceps,
brachioradialis, patellar, and achilles
tendons.
SPINAL CORD INJURY
• Damage to the spinal cord can
disrupt ascending tracts to the brain,
resulting in the loss of sensation.
Conversely, the disruption of
descending tracts from the brain to
motor neurons in the spinal cord can
result in the loss of motor functions.
• Leading causes are automobile and
motorcycle accidents, followed by
gunshot wounds, falls, and
swimming accidents.
• The primary mechanisms include
concussion (an injury caused by a
blow), contusion (an injury resulting
in hemorrhage), and laceration (a
tear or cut).
• Spinal cord injuries often involve
excessive flexion, extension,
rotation, or compression of the
vertebral column.
• Most spinal cord injuries are acute
contusions of the cord due to bone
or disk displacement into the cord
and involve a combination of
excessive directional movements,
such as simultaneous flexion and
compression.
• Spinal cord injury is classified
according to the vertebral level at
which the injury occurred.
• Most spinal cord injuries occur in
the cervical region or at the
thoracolumbar junction.
• Injuries in the cervical region above
t1 are the most severe and can result
in quadriplegia or tetraplegia, with
the abdominal and chest muscles
also affected.
• Injuries at or below t1 can result in
varying degrees of paralysis of the
legs (paraplegia) and the abdomen,
while retaining full function of the
upper limbs.
• At the time of spinal cord injury, two
types of tissue damage occur:
• Primary, mechanical damage
• Secondary, tissue damage extending
into a much larger region of the cord
than the primary damage. Secondary
spinal cord damage begins within
minutes of the primary damage and
is caused by ischemia, edema, and
the release of “excitotoxins” (such as
glutamate), and inflammatory cell
invasion.
TREATMENT
• Treatment with large doses of anti-
inflammatory steroids, such as
methylprednisolone, within 8 hours
of the injury can dramatically lessen
the secondary damage to the cord by
reducing inflammation and edema.
• Additional treatments include
structural realignment and
stabilization of the vertebral column.

• Rehabilitation

Cardiovascular System
HEART
 The heart is an organ that is essential
for life.
 The heart is a member organ of the
cardiovascular system, which
consists of the heart, blood vessels,
and blood.
 The heart of a healthy adult, at rest,
pumps approximately 5 liters (L) of
blood per minute.
  For most people, the heart continues
to pump at approximately that rate
for more than 75 years.
 The heart is a muscular organ
containing four chambers. Its main
function is to pump blood around
the circulatory system of the lungs
and the systemic circulation of the
rest of the body.
 In the average day the heart beats
about 100,000 times and never rests.
It must continue its cycle of
contraction and relaxation in order to
provide a continuous blood supply
to the tissues and ensure the delivery
of nutrients and oxygen and the
removal of waste products
 The heart is actually two pumps in
one, with the heart’s right side
pumping to the lungs and back to
the left side of the heart through
vessels of the pulmonary
circulation.
 The left side of the heart pumps
blood to all other tissues of the body
and back to the right side of the
heart through vessels of the
systemic circulation
FUNCTIONS OF THE HEART
1. Generates blood pressure
2. Routes blood
3. Ensures one- way blood flow
4. Regulates blood supply
SIZE OF THE HEART
 The heart weighs 250–390 g in men
and 200–275 g in women and is a
little larger than the owner’s closed
fist, being approximately 12 cm
long and 9 cm wide (Jenkins and
Tortora, 2013).
HEART LOCATION
 It is located in the thoracic cavity
(chest) in the mediastinum
(between the lungs), behind and to
the left of the sternum (breastbone).
apex (bottom) towards left side
HEART WALL
 Pericardium or pericardial sac, is a
double layered, closed sac that
surrounds the heart.
 It consists of a tough, fibrous
connective tissue outer layer called
the fibrous pericardium and a thin,
transparent, inner layer of simple
squamous epithelium called the
serous pericardium.
 The fibrous pericardium, a tough,
inelastic layer made up of dense,
irregular, connective tissue. The role
of this layer is to prevent the
overstretching of the heart. It also
provides protection to the heart and
anchors it in place
 The serous pericardium, a thinner,
more delicate, layer that forms a
double layer around the heart:
 The parietal pericardium, the outer
layer fused to the fibrous
pericardium;
 The visceral pericardium
(otherwise known as the
epicardium) adheres tightly to the
surface of the heart.
PERICARDITIS
 Pericarditis is an inflammation of the
 serous pericardium.
 The cause is frequently unknown,
but it can result from infection,
diseases of connective tissue, or
damage due to radiation treatment
for cancer.
 The condition can cause extremely
painful sensations that are referred to
the back and chest and can be
 confused with a myocardial
infarction.
 Pericarditis can lead to fluid
accumulation within the pericardial
sac.
CARDIAC TAMPONADE
 Cardiac tamponade is a potentially
fatal condition in which a large
volume of fluid or blood
accumulates in the pericardial cavity
and compresses the heart from the
outside.
 When it is compressed by fluid
within the pericardial cavity, it
cannot expand when the cardiac
muscle relaxes. Consequently, it
cannot fill with blood during
relaxation; therefore, it cannot pump
blood.
 Cardiac tamponade can cause a
person to die quickly unless the fluid
is removed.
 Causes of cardiac tamponade
include rupture of the heart wall
following a myocardial infarction,
rupture of blood vessels in the
pericardium after a malignant tumor
has invaded the area, damage to the
pericardium due to radiation therapy,
and trauma, such as that resulting
from a traffic accident.
MYOCARDIUM
 Myocardium is composed of cardiac
muscle cells and is responsible for
the heart’s ability to contract. It is a
type of muscle only found within the
heart and is specialized in its
structure and function.
 The myocardium can be divided into
two categories: the majority is
specialized to perform contraction,
and the remainder is specialized to
the task of initiating and conducting
electrical impulses.
ENDOCARDIUM
 The endocardium is a layer of
smooth simple epithelium lining the
inside of the heart muscle and the
heart valves. It is connected
seamlessly with the lining of the
large blood vessels that are
connected to the heart.
HEART EXTERNAL ANATOMY
 The superior vena cava and the
inferior vena cava carry blood from
the body to the right atrium, and
four pulmonary veins carry blood
from the lungs to the left atrium.
 The smaller coronary sinus carries
blood from the walls of the heart to
the right atrium
 Two arteries, the aorta and the
pulmonary trunk, exit the heart. The
aorta carries blood from the left
ventricle to the body, and the
pulmonary trunk carries blood from
the right ventricle to the lungs.
 A large coronary sulcus runs
obliquely around the heart,
separating the atria from the
ventricles.
 The anterior interventricular sulcus is
on the anterior surface of the heart,
and the posterior interventricular
sulcus (groove) is on the posterior
surface of the heart.
 In a healthy, intact heart, the sulci are
covered by adipose tissue, and only
after this tissue is removed can they
be seen.
BLOOD SUPPLY TO THE
HEART
 The major arteries supplying blood
to the tissue of the heart lie
within the coronary sulcus and
interventricular sulci on the surface
of the heart.
 The right and left coronary arteries
exit the aorta just above the point
where the aorta leaves the heart and
lie within the coronary sulcus.
 The right coronary artery is usually
smaller in diameter than the left one,
and it does not carry as much blood
as the left coronary artery.
 A major branch of the left coronary
artery, called the anterior
interventricular artery, or the left
anterior descending artery, extends
inferiorly in the anterior
interventricular sulcus and supplies
blood to most of the anterior part of
the heart.
 The left marginal artery branches
from the left coronary artery to
supply blood to the lateral wall of
the left ventricle.
 The circumflex artery branches from
the left coronary artery and extends
around to the posterior side of the
heart in the coronary sulcus. Its
branches supply blood to much of
the posterior wall of the heart.
 The right coronary artery lies within
the coronary sulcus and extends
from the aorta around to the
posterior part of the heart.
 A larger branch of the right coronary
artery, called the right marginal
artery, and other branches supply
blood to the lateral wall of the right
ventricle.
 A branch of the right coronary
artery, called the posterior
interventricular artery, lies in the
posterior interventricular sulcus and
supplies blood to the posterior and
inferior part of the heart.
 Blood flow through the coronary
blood vessels is not continuous.
When the cardiac muscle contracts,
blood vessels in the wall of the heart
are compressed, and blood does not
readily flow through them.
 When the cardiac muscle is relaxing,
the blood vessels are not
compressed, and blood flow through
the coronary blood vessels resumes.
 In a resting person, blood flowing
through the coronary arteries gives
up approximately 70% of its oxygen.
 The percentage of oxygen delivered
to cardiac muscle is near its
maximum at rest, it cannot increase
substantially during exercise.
Therefore, cardiac muscle requires
blood to flow through the coronary
arteries at a higher rate than its
resting level in order to provide an
adequate oxygen supply during
exercise.
THE MAJOR VEIN DRAINING
THE HEART
 The great cardiac vein, and a small
cardiac vein drains the right margin
of the heart. These veins converge
toward the posterior part of the
coronary sulcus and empty into a
large venous cavity called the
coronary sinus, which in turn
empties into the right atrium.
 A number of smaller veins empty
into the cardiac veins, into the
coronary sinus, or directly into the
right atrium.
THE HEART CHAMBERS
 Atria are the smaller chambers of
the heart and lie superior to (above)
the ventricles. There are two atria:
 The right atrium receives blood
from three veins – the superior vena
cava, the inferior vena cava and the
coronary sinus.
 The left atrium forms most of the
base of the heart and receives blood
from the lungs through four
pulmonary veins.
 The right ventricle receives blood
from the right atrium and pumps
this blood out into the pulmonary
circulation (the lungs). As the
pressure in the pulmonary
circulation is quite low the right
 ventricle has a thinner wall than the
left ventricle.
 The left ventricle receives blood
from the left atrium and pumps this
blood out into the systemic
circulation (the rest of the body) via
the aorta. As the left ventricle has to
pump against a higher pressure and
over a greater distance it has a much
thicker (more muscular) wall.
ATRIOVENTRICULAR VALVES
 the tricuspid valve is made up
of three cusps (leaflets) and lies
between the right atrium and the
right ventricle
 the bicuspid (mitral) valve is
made up of two cusps and lies
between the left atrium and the
left ventricle
VALVULAR CONTROL
 Each ventricle contains cone-shaped,
muscular pillars called papillary
muscles.
 These muscles are attached by
strong, connective tissue strings
called chordae tendineae to the free
margins of the cusps of the
atrioventricular valves.
SEMILUNAR VALVES
 the pulmonary valve lies between
the right ventricle and the pulmonary
arteries and prevents the backward
flow of blood into the right ventricle
from the pulmonary arteries.
 the aortic valve lies between the left
ventricle and the aorta and prevents
the backward flow of blood into the
left ventricle from the systemic
circulation.
CARDIAC MUSCLE ACTION
POTENTIALS
1. The movement of Na+ through the
voltage- gated Na+ channels causes
depolarization.
2. During depolarization, voltage-gated
K+ channels close, and voltage
gated Ca2+ channels begin to open.
3. Early repolarization results from
closure of the voltage-gated Na+
channels and the opening of some
voltage-gated K+ channels.
4. The plateau exists because voltage-
gated Ca2+ channels remain open.
5. The rapid phase of repolarization
results from closure of the voltage
gated Ca+ channels and the opening
of many voltage-gated K+ channels.
6. The entry of Ca2+ into cardiac
muscle cells causes Ca2+ to be
released from the sarcoplasmic
reticulum to trigger contractions.
CONDUCTION SYSTEM OF
HEART
 Contraction of the atria and
ventricles is coordinated by
specialized cardiac muscle cells in
the heart wall that form the
conduction system of the heart.
 The conduction system of the heart
includes the sinoatrial node,
atrioventricular node, atrioventricular
bundle, right and left bundle
branches, and Purkinje fibers.
SINOATRIAL NODE
 Normal electrical
excitation/distribution begins in
the sinoatrial (SA) node, which
is located in the right atrium, and
is rapidly transmitted across the
atria by fast pathways. This
ensures that the right and left
atria are excited together and
beat as one unit.
 Functions as pacemaker
  large number of Ca2+ channels
ATRIOVENTRICULAR NODE
 Atrioventricular node (AV node),
located in the lower portion of the
right atrium.
 Action potentials from SA node sent
to this node
 Further transmission is delayed for
approximately 0.1 s (Martini et al.,
2014). Slow rate of action potential
conduction allows the atria to
complete their contraction before
action potentials are delivered to the
ventricles.
ATRIOVENTRICULAR BUNDLE
 action potentials from AV node
travel to AV bundle
 AV bundle divides into a left and
right bundle branches
PURKINJE FIBERS
 at the tips of the left and right
bundle branches, are Purkinje fibers.
 Purkinje fibers pass to the apex of
the heart and then extend to the
cardiac muscle of the ventricle walls
 action potentials are rapidly
delivered to all the cardiac muscle of
the ventricles
ELECTROCARDIOGRAM (ECG)
 ECG is a test that measures the
heart's electrical activity. It's also
known as an ECG or EKG.
 Electrodes placed on the body
surface and attached to an
appropriate recording device can
detect small voltage changes
resulting from action potentials in
the cardiac muscle.
 ECG detect a summation of all the
action potentials transmitted by the
cardiac muscle cells through the
heart at a given time. The summated
record of the cardiac action
potentials is an electrocardiogram
 The normal ECG consists of a P
wave, a QRS complex, and a T
wave.
 The P wave, which is the result of
action potentials that cause
depolarization of the atrial
myocardium, signals the onset of
atrial contraction.
 The QRS complex is composed of
three individual waves: the Q, R,
and S waves.
 The QRS complex results from
ventricular depolarization and
signals the onset of ventricular
contraction.
 The T wave represents
repolarization of the ventricles and
precedes ventricular relaxation.
 uA wave representing repolarization
of the atria cannot be seen because it
occurs during the QRS complex.
 The time between the beginning of
the P wave and the beginning of the
QRS complex is the PQ interval,
commonly called the PR interval
because
 The PR interval, which lasts
approximately 0.16 second, the atria
contract and begin to relax.
 The ventricles begin to depolarize at
the end of the PR interval
 The QT interval extends from the
beginning of the QRS complex to the
end of the T wave, lasting
approximately 0.36 second.
 The QT interval represents the
approximate length of time required
for the ventricles to contract and
begin to relax.
CARDIAC CYCLE
 cardiac cycle refers to the repetitive
pumping process that begins with the
onset of cardiac muscle contraction
and ends with the beginning of the
next contraction.
  Atrial systole: contraction of atria
 Ventricular systole: contraction of
ventricles
 Atrial diastole: relaxation of atria
 Ventricular diastole: relaxation of
ventricles
HEART SOUNDS
 The first heart sound is a low-
pitched sound, often described as
“lubb.” It is caused by vibration of
the atrioventricular valves and
surrounding fluid as the valves close
at the beginning of ventricular
systole.
 The second heart sound is a higher-
pitched sound often described as
“dupp.” It results from closure of the
aortic and pulmonary semilunar
valves, at the beginning of
ventricular diastole.
 A faint third heart sound can be
heard in some normal people,
particularly those who are thin and
young.
 It is caused by blood flowing in a
turbulent fashion into the ventricles,
and it can be detected near the end
of the first one-third of diastole.
REGULATION OF HEART
FUNCTION
 Stroke Volume: volume of blood
pumped per ventricle per
contraction. 70 milliliters/beat
 Heart Rate: number of heart beats in
1 min, the normal is 60-100
beats/min.
 Lower than 60 beats per minute is
called bradycardia
 More than 100 beats per minute is
called tachycardia.
 Cardiac Output: volume of blood
pumped by a ventricle in 1 min. 5
Liters/min.
 Cardiac output equals stroke volume
multiplied times heart rate
 CO = SV x HR
 Example: SV is 70 mL and the heart
rate is 75,
 Cardiac output is 70 X 75= 5250 mL
(or 5.25 L) per minute.
INTRINSIC REGULATI ON OF
THE HEART
 Intrinsic regulation refers to the
mechanisms contained within the
heart itself that control cardiac
output.
 Venous return: the amount of blood
that returns to heart
 Preload: the degree ventricular walls
are stretched at end of diastole
 After load: pressure against which
ventricles must pump blood
EXTRINSIC REGULATION OF
HEART
 The cardioregulatory center in the
medulla oblongata regulates
parasympathetic and sympathetic
nervous control of the heart.
 Parasympathetic stimulation is
supplied by the vagus nerve.
 Postganglionic neurons secrete
acetylcholine, which increases
membrane permeability to K+,
producing hyperpolarization of the
membrane.
 Parasympathetic stimulation
decreases heart rate.
 Sympathetic stimulation is supplied
by the cardiac nerves.
 Postganglionic neurons secrete
norepinephrine, which increases
membrane permeability to Na+ and
Ca2+ and produces depolarization
of the membrane.
 Sympathetic stimulation increases
heart rate and force of contraction.
 Epinephrine and norepinephrine are
released into the blood from the
adrenal medulla as a result of
sympathetic stimulation.
  Epinephrine and norepinephrine
increase the rate and force of heart
contraction.
BARORECEPTOR REFLEX
 The baroreceptor reflex is a
mechanism of the nervous system
that plays an important role in
regulating heart function.
 Baroreceptors monitor blood
pressure the aorta and carotid
arteries.
 In response to a decrease in blood
pressure, the baroreceptor reflexes
increase sympathetic stimulation
and decrease parasympathetic
stimulation of the heart, resulting in
increased heart rate and force of
contraction.
EFFECTS OF AGING ON THE
HEART
 Aging results in gradual changes in
heart function, which are minor
under resting conditions but more
significant during exercise.
 Hypertrophy of the left ventricle is a
common age-related condition.
 The maximum heart rate declines so
that, by age 85, the cardiac output
may be decreased by 30–60%.
 There is an increased tendency for
valves to function abnormally and
for arrhythmias to occur.
 Because increased oxygen
consumption is required to pump the
same amount of blood, age-related
coronary artery disease is more
severe.
 Exercise improves the functional
capacity of the heart at all ages.
HEART DISEASE
 Coronary artery disease or CAD is
characterized by the accumulation of
plaque within the layers of the
coronary arteries.
 The plaques progressively enlarge,
thicken, and calcify, causing a
critical narrowing (70% occlusion)
of the coronary artery lumen,
resulting in a decrease in coronary
blood flow and an inadequate supply
of oxygen to the heart muscle.
PATHOPHYSIOLOGY AND
ETIOLOGY OF CAD
 The most widely accepted cause of
CAD is atherosclerosis.
 The person with atherosclerosis has a
classic supply- and-demand
problem.
 The heart may function without
problem until increases in activity or
other stresses place a demand on it
to beat faster or harder.
 The heart muscle then becomes
hypoxic. This imbalance between
oxygen supply and demand is
manifested as pain, or angina
pectoris, which literally means
“suffocation of the Chest”
 Angina is usually precipitated by
physical exertion or emotional
stress, which puts an increased
demand on the heart to circulate
more blood and oxygen.
 The ability of the coronary artery to
deliver blood to the myocardium is
impaired because of obstruction by a
significant coronary lesion.
 the heart muscle does not have any
pain fibers, a substance called factor
P is released from ischemic
myocardial cells, and pain is felt
wherever substance P reacts with a
pain receptor.
 For many people this is the chest,
and for others it is the left arm;
others have pain in the jaw and teeth.
RISK FACTORS FOR THE
DEVELOPMENT OF CAD
 Nonmodifiable: age (risk increases
with age), male sex, race (nonwhite
 populations have increased risk), and
family history.
 Modifiable: elevated lipid levels,
hypertension, obesity, tobacco use,
metabolic syndrome (obesity,
hypertension, and diabetes mellitus),
sedentary lifestyle, stress.
TYPE OF ANGINA
1. Stable angina is chest pain or
discomfort that most often occurs
with activity or emotional stress.
 There is no damage to heart
muscle
 chest discomfort is relieved
with rest, nitroglycerin or
both.
2. Chronic Angina
 Stable angina can go on for a
long time with no resultant
myocardial infarction (MI).
 Chronic angina is a prevalent
manifestation of chest pain or
discomfort that most often
occurs with activity or
emotional stress.
3. Unstable Angina
 Unstable Angina is chest pain
that occurs at rest, it means
that the narrowing of the
coronary arteries becomes
more pronounced.
 no damage to heart muscle
occurs, the person is at
increased risk of a complete
blockage of blood supply to
the heart muscle if the heart
needs to work harder or the
oxygen demand increases.
MYOCARDIAL INFARCTION
(HEART ATTACK)
 Myocardial Infarction
 occurs when blood flow decreases or
stops to a part of the heart,.
 The area of muscle that depends on
that vessel for oxygen becomes
ischemic and then necrotic.
 Symptoms chest pain or discomfort
which may travel into the shoulder,
arm, back, neck or jaw.
TREATMENT
 Thrombolysis – the administration of
a thrombolytic drug in order to try to
break up the clot and return blood
flow through the artery.
 This form of treatment is very
common and requires no specialist
equipment to administer. However,
patients are closely monitored for
side effects, including bleeding,
hypotension and disturbances in the
heart rhythm
 Percutaneous transluminal
angioplasty -a balloon-tipped
catheter is placed in a coronary
vessel narrowed by plaque.
 The balloon is inflated and deflated
to stretch the vessel wall and flatten
the plaque.
 Blood flows freely through the
unclogged vessel to the heart.
 Intracoronary atherectomy - a blade-
tipped catheter is guided into a
coronary vessel to the site of the
plaque.
 Depending on the type of blade, the
plaque is either cut, shaved, or
pulverized, and then removed
 Intracoronary stent- a diamond
mesh tubular device is placed in the
coronary vessel.
 Prevents restenosis by providing a
“skeletal” support.
SURGICAL TREATMENT
 Coronary artery bypass graft
 (CABG) surgery.
 uA graft is surgically attached to the
aorta, and the other end of the graft
is attached to a distal portion of a
coronary vessel.
 Bypasses obstructive lesions in the
vessel and returns adequate blood
flow to the heart muscle supplied by
the artery.

SPECIAL SENSES
SENSES
• Sense: ability to perceive stimuli
• Sensation: conscious awareness of
stimuli received by sensory neurons
• Sensory receptors: sensory nerve
endings that respond to stimuli by
developing action potentials

T Y P E S OF S E N S E S
• General senses: receptors over large
part of body that sense touch,
pressure, pain, temperature, and itch.

 Somatic provide information about

body and environment

 visceral provide information about

internal organs

• Special senses: smell, taste, sight,

hearing, and balance

TYPESOF RECEPTOR
S
 • Mechanoreceptors: is a sensory cell
that responds to mechanical pressure
or distortion, it detect movement.
• Chemoreceptors: detect chemicals
in the environments that depends
primarily on the sense of smell.
• Photoreceptors: are the cells in the
retina that respond to light.
• Thermoreceptors: are specialized
nerve cells that are able to detect
differences in temperature.
• Nociceptors: ("pain receptor") is a
sensory neuron that responds to
damaging or potentially damaging
stimuli by sending signals to the
spinal cord and the brain.
TYPESOF TOUCH RE
CEPTORS
• Merkel’s disk: nerve endings that
respond to light touch; they are
present in the upper layers of skin.
• Hair follicle receptors: are nerve
ending that sends and receives
impulses to and from the brain when
the hair moves. They detect light
touch upon hair movement.
• Meissner corpuscle: deep in
epidermis localizing light touch
tactile sensations.
• Ruffini corpuscle: are deep tactile
receptors found in the superficial
dermis of both hairy and glaborous
skin where they record low-
frequency vibration or pressure,
theydetects continuous pressure in
skin
• Pacinian corpuscle: are deepest
receptors in the skin and also
associated with tendons and joints,
detect deep pressure, vibration,
position.
O L FA C T I O N
• Olfaction is the sense of smell,
occurs in response to odorants
• Olfaction is dependent on receptors
that respond to airborne particles.
• Receptors are located in nasal cavity
and hard palate, that can detected
10,000 different smells.
• The olfactory epithelium contains
approximately 10 million olfactory
neurons.
• Olfactory nerves, formed by the
axons of these bipolar neurons,
project through numerous small
foramina in the bony cribriform
plate to the olfactory bulbs.
• The axons synapse with secondary
neurons of the olfactory bulb. From
the bulbs, olfactory tracts project to
the cerebral cortex.
• The dendrites of olfactory neurons
extend to the epithelial surface of
the nasal cavity, and their ends are
modified into bulbous enlargements
called olfactory vesicles .
• These vesicles possess cilia called
olfactory hairs, which lie in a thin
mucous film on the epithelial
surface.
O L FA C T I O N P R O C E S S
• Airborne molecules enter the nasal
cavity and are dissolved in the fluid
covering the olfactory epithelium.
• Some of these molecules, referred to
as odorants, bind to transmembrane
odorant receptor molecules
(chemoreceptors) of the olfactory
hair membranes.
 • Dendrites pick up odor, depolarize,
and carry odor to axons in olfactory
bulb (cranial nerve I).
• At the olfactory bulbs the axons
converge to connect with
postsynaptic (mitral) cells in large
synaptic structures called glomeruli.
• Axons exiting from the olfactory
bulbs travel along the olfactory
nerves (cranial nerve I, which is a
paired nerve) to reach the olfactory
cortex, the hypothalamus and
portions of the limbic system via the
olfactory tracts.
CENTRAL A D A P TAT I O
N to 12 of these papillae form a V-
• Have you ever noticed that when
meeting someone during the day you
will smell their perfume or
aftershave, but having spent some
time with them you will no longer be
aware of that smell?
• This is a function of central
adaptation. Higher centers in the
brain are responsible for our reduced
perception of a persistent smell. The
transmission of the sensory
information for that particular smell
is inhibited at the level of the
olfactory bulb by nerve impulses
from the centers in the brain.
TA S T E
• Taste buds: sensory structures that
detect taste or gustatory, located on
papillae on tongue, hard palate,
throat.
• Inside each taste bud are 40 taste
cells, each taste cell has taste hairs
that extend into taste pores.
• Taste buds are also located on other
areas of the tongue, the palate, and
even the lips and throat, especially
in children.
FOUR MAJ ORTYPES
OF
PAPILLAE
• Filiform papillae are the most
numerous papillae on the surface of
the tongue but have no taste buds.
Rather, filiform papillae provide a
rough surface on the tongue,
allowing it to manipulate food more
easily.
• Vallate papillae are the largest but
least numerous of the papillae. Eight
shaped row along the border
between the anterior and posterior
parts of the tongue.
• Foliate papillae are distributed in
folds on the sides of the tongue and
contain the most sensitive of the
taste buds. They are most numerous
in young children and decrease with
age. In adults, they are located
mostly posteriorly.
• Fungiform papillae are scattered
irregularly over the entire superior
surface of the tongue, appearing as
small, red dots interspersed among
the far more numerous filiform
papillae.
H I S T O L O G Y O F TA S T E
BUDS
• Taste buds are oval structures
embedded in the epithelium of the
tongue and mouth. Each of the
10,000 taste buds on a person’s
tongue consists of three major types
of specialized epithelial cells.
• The sensory cells of each taste bud
consist of about 50 taste cells, or
gustatory cells.
 • The remaining two cell types, which
are nonsensory cells, are basal cells
and supporting cells. the taste cells
are replaced continuously, each
having a normal life span of about
10 days.
• Each taste cell has several microvilli,
called taste hairs, or gustatory hairs,
extending from its apex into a tiny
opening in the epithelium called the
taste pore, or gustatory pore.
T H ETA S T E R E C E P T O R
• The activation of the taste receptor
requires the chemical compound that
is to be tasted to dissolve in the
saliva, then diffuse into the taste pore
and come into contact with the
gustatory hairs.
PATHWAYSFORTHE S
ENSEOF
TASTE
• The release of neurotransmitters by
the gustatory cells creates an action
potential in related afferent nerve
fibers.
• The sensory information from the
tongue is transmitted along two
cranial nerve pairs
• chorda tympani – a branch of the
facial nerve (CN VII) relays
impulses from the anterior two‐
thirds of the tongue.
• lingual branch of the
glossopharyngeal nerve (CN IX) –
carries the sensory information of
the posterior third of the tongue.
• Sensory information from the taste
buds in the epiglottis and pharynx is
transmitted by the vagus nerve
(cranial nerve X).
• All the afferent fibers terminate in
the solitary nucleus of the medulla.
• The sensory messages are then
transmitted, ultimately, to the
thalamus and the gustatory cortex in
the parietal lobes.
• Afferent fibers also project into the
hypothalamus and limbic system.
• Ultimately, many of the branches of
afferent nerves that divert to various
parts of the brain, apart from the
cortex, are involved in the triggering
of reflexes involved with digestion.
VISION
ACCESSORY STRUCTURES
• Eyebrows prevent perspiration from
running down the forehead and into
the eyes and irritating them.
Eyebrows also help shade the eyes
from direct sunlight.
• Eyelids, or palpebrae, with their
associated lashes, continual blinking
keeps the surface of the eye
lubricated and removes dirt, protect
the eyes from foreign objects and
also help regulate the amount of light
entering the eye.
• The space between the two eyelids is
called the palpebral fissure, and the
angles where the eyelids join at the
medial and lateral margins of the
eye are called canthi.
• The medial canthus contains a small,
reddish-pink mound called the
caruncle, which houses some
modified sebaceous and sweat
glands.
• Eyelashes – robust hairs that help to
keep foreign matter out of the eyes.
They are associated with the tarsal
glands, which produces sebum that
lubricates the lids and restrains tears
from flowing over the margin of the
eyelids

SK E L E T A L M U S C L E S T
HAT
CONTROL THE MOVEM
E N T O F EYELIDS
• The orbicularis oculi muscle closes
the lids, and the levator palpebrae
superioris elevates the upper lid
C O N J U N C T I VA
• The conjunctiva is a thin, transparent
mucous membrane.
• The palpebral conjunctiva covers the
inner surface of the eyelids, and the
bulbar conjunctiva covers the
anterior white surface of the eye.
• The secretions of the conjuctiva help
lubricate the surface of the eye.
CONJUNCTIVITIS
• Conjunctivitis is an inflammation of
the conjunctiva caused by an
infection or other irritation.
• One type of conjunctivitis caused by
a bacterium is acute contagious
conjunctivitis, also called pinkeye.
• Viral conjunctivitis is highly
contagious.it can spread through
hand-to-eye contact by hands or
objects that are contaminated with
the infectious virus.
LACRIMAL APPARATUS
• The lacrimal apparatus consists of a
lacrimal gland, lacrimal canaliculi,
lacrimal sac and nasolacrimal duct.
• The lacrimal gland is innervated by
parasympathetic fibers from the
facial nerve (VII).
• The gland produces tears, which
leave the gland through several
lacrimal ducts and pass over the
anterior surface of the eyeball.
• The gland produces tears constantly
at the rate of about 1 mL/day to
moisten the surface of the eye,
lubricate the eyelids, and wash away
foreign objects
E X T R I N S I CE Y E M U S C L
ES
• Six extrinsic muscles of the eye
cause the eyeball to move.
• Four of these muscles run more or
less straight anteroposteriorly: the
superior, inferior, medial, and lateral
rectus muscles.
• Two other muscles, the superior and
inferior oblique muscles, are
positioned at an angle to the globe
of the eye.
E Y EM O V E M E N T
• The movements of the eye can be
described graphically by a figure
resembling the letter H.
• The clinical test for normal eye
movement is therefore called the H
test. A person’s inability to move
the eye toward one part of the H
may indicate dysfunction of either an
extrinsic eye muscle or the cranial
nerve to the muscle.
A N AT O M Y OF THE EY
E
• The wall of the eyeball is composed
of three tunics, or layers.
• The outer fibrous tunic consists of
the sclera and cornea
• The middle vascular tunic consists of
the choroid, ciliary body, and iris
 • The inner nervous tunic consists of
the retina
FIBROUS TUNIC
• Sclera is the firm, opaque, white,
outer layer of the posterior five
sixths of the eyeball. It consists of
dense collagenous connective tissue
with elastic fibers.
• The sclera helps maintain the shape
of the eyeball, protects its internal
structures, and provides an
attachment point for the muscles
that move it.
• Cornea is an avascular, transparent
structure that permits light to enter
the eye and bends, or refracts, that
light as part of the eye’s focusing
system.
• The cornea is transparent because
fewer large collagen fibers and more
proteoglycans are present and it has
low water content.
• The central part of the cornea
receives oxygen from the outside air
CORNEALTRANSPLAN
T •
• The cornea was one of the first
organs to be transplanted.
• Several characteristics make it
relatively easy to transplant:
 It is easily accessible and relatively
easily removed
 it is avascular, so it does not require
extensive circulation, as other
tissues do.
 it is less immunologically active and
therefore less likely to be rejected
than other tissues are.
VA S C U L A R T U N I C
• Vascular tunic is the middle tunic of
the eyeball, it contains most of the
blood vessels of the eyeball.
• The portion of vascular tunic
associated with the sclera of the eye
is the choroid.
• Anteriorly, the vascular tunic
consists of the ciliary body and the
iris.
IRIS
• Iris is the central and colored portion
of the eye
• A large amount of melanin in the iris
causes it to appear brown or even
black. Less melanin results in light
brown, green, or gray irises. Even
less melanin causes the eyes to
appear blue.
• If there is no pigment in the iris, as
occurs in albinism the iris appears
pink.
• The iris is a contractile structure,
consisting mainly of smooth muscle,
surrounding an opening called the
pupil.
Light enters the eye through the
pupil, and the iris regulates the
amount of light by controlling the
size of the pupil.
SMOOTH MUSCES OF THE IRIS
• The Sphincter pupillae is a circular
muscle of the iris that innervated by
parasympathetic fibers from the
oculomotor nerve (III). When they
contract, the iris decreases, or
constricts, the size of the pupil
• The Dilator pupillae are innervated
by sympathetic fibers. When they
contract, the pupil is dilated.
C I L I A RY B O DY
 • The greatest part of the ciliary body
is made up of the ciliary muscle, a
smooth muscular ring that projects
into the interior of the eye.
• The ciliary muscle controls
accommodation for viewing objects
at varying distances.
• The ciliary body produces the fluid
in the eye called aqueous humor
CHOROID
• The choroid is a vascular layer that
separates the fibrous and neural
tunics. It is covered by the sclera and
attached to the outermost layer of
the retina. The choroid contains an
extensive capillary network that
delivers oxygen and nutrients to the
retina.
RETINA
• The retina is the innermost layer of
the eye, consisting of a thin outer
layer called the pigmented part and a
thicker inner layer called the neural
part.
• The pigmented part of the retina
absorbs the light that passes through
the neural part; this prevents light
bouncing back through the neural
part and causing ‘visual echoes
• The neural layer contains numerous
photoreceptor cells: 120 million rods
and 6 or 7 million cones, as well as
numerous relay neurons. The neural
layer is responsible for the
preliminary processing and
integration of visual information.
• The macula is a small yellow spot,
approximately 4 mm in diameter,
near the center of the posterior
retina. In the center of the macula is
a small pit, the fovea centralis.
• The fovea centralis is the region of
the retina where light is most
focused when the eye is looking
directly at an object. The fovea
centralis contains only cone cells,
and the cells are more tightly packed
there than any where else in the
retina.
OPTIC DISC
• The optic disc is a white spot just
medial to the macula through which
the central retinal artery enters and
the central retinal vein exits the
eyeball.
• Branches from these vessels spread
over the surface of the retina. This is
also the spot where nerve processes
from the neural layer of the retina
meet, pass through the two outer
tunics, and exit the eye as the optic
nerve.
• The optic disc contains no
photoreceptor cells and does not
respond to light; therefore, it is called
the blind spot of the eye.
C H A M B E R SO F T H E E Y E
• The interior of the eye is divided into
three chambers: the anterior
chamber, the posterior chamber, and
the vitreous chamber.
• The anterior chamber lies between
the cornea and the iris, and the
smaller posterior chamber lies
between the iris and the lens. These
two chambers are filled with
aqueous humor
AQUEOUS HUMOR
• Aqueous humor helps maintain
intraocular pressure. The pressure
within the eyeball keeps it inflated
 and is largely responsible for
maintaining the eyeball’s shape.
• The aqueous humor also refracts
light and provides nutrition for the
structures of the anterior chamber,
such as the avascular cornea.
• Aqueous humor is produced by the
ciliary processes as a blood filtrate
and is returned to the circulation
through a venous ring at the base of
the cornea called the scleral venous
sinus.
C H A M B E R SO F T H E E Y E
• The vitreous chamber of the eye is
much larger than the anterior and
posterior chambers. It is almost
completely surrounded by the retina
and is filled with a transparent,
jellylike substance called vitreous
humor.
• the vitreous humor helps maintain
intraocular pressure and therefore
the shape of the eyeball, and it holds
the lens and retina in place. It also
functions in the refraction of light in
the eye.
LENS
• Lens is transparent and biconvex,
with the greatest convexity on its
posterior side.
• The lens is suspended between the
posterior chamber and the vitreous
chamber by the suspensory
ligaments of the lens, which are
connected from the ciliary body to
the lens capsule.
• The lens capsule is a thin membrane
around the eye's natural lens. The
capsule helps give the lens its shape.
• Within the lens are lens fibers,
specialized cells that have lost their
nucleus and other organelles. They
are filled with a protein called
crystallin, which is responsible for
the transparency and the focusing
power of the lens.
• The process of changing the shape of
the lens to focus an image onto the
retina is known as accommodation.
FUNCTIONS OF TH
E EYE
• The eye functions much like a
camera.
• The iris allows light into the eye,
which is focused by the cornea, lens,
and humors onto the retina.
• The light striking the retina produces
action potentials that are relayed to
the brain.
• Light refraction and image focusing
are two important processes in
establishing vision. The majority of
the refraction in the eye happens
when light enters the cornea from
the air; additional refraction occurs
when light passes from the aqueous
humour into the lens.
• Focal point: a point where light rays
converge, occurs anterior to retina.
object is inverted
• Accommodation: lens becomes less
rounded and image can be focused
on retina enables eye to focus on
images closer than 20 feet.
V I S U A L P AT H W AY S T O
THE
BRAIN
• Image formation begins when eye
structures refract light rays from an
object.
 • Normally, the cornea, aqueous
humor, lens, and vitreous humor
refract light rays from an object,
focusing them on the fovea centralis,
where an inverted and reversed
image clearly forms. m
• Within the retina, rods and cones
turn the projected image into an
impulse and transmit it to the optic
nerve.
• The impulse travels to the optic
chiasm, and then continues into the
optic section of the cerebral cortex.
• There, the inverted and reversed
image on the retina is processed by
the brain to create an image as it
truly appears in the field of vision.
VI SUAL ACUITY
• Visual acuity is the eye’s ability to
focus an image on the retina so that
a clear image is perceived. Many
factors affect visual acuity,
including the shape of the eyeball
and the flexibility of the lens.
• Visual acuity is tested using a
standard size Snellen chart at 20 feet
and lit to a standard brightness.
• 20/20 vision refers to a measure of
visual acuity. The meaning is that
the person being tested can see the
same detail from 20 feet away as a
person with normal eyesight would
see from 20 feet.
• If a person has 20/40 vision they are
only able to see detail at 20 feet that
a person with normal vision can see
at 40 feet
VI SUAL DEFECTS
• Myopia is nearsightedness, a defect
of the eye in which the focusing
system, the cornea and lens, is
optically too powerful, or the
eyeball is too long (axial myopia).
As a result, the focal point is too
near the lens, and the image is
focused in front of the retina.
• Myopia is corrected by a concave
lens that counters the refractive
power of the eye
• Radial keratotomy s a refractive
surgical procedure to correct myopia
(nearsightedness) that was developed
in 1974, by Svyatoslav Fyodorov.
Radial keratotomy consists of
making a series of four to eight
radiating cuts in the cornea.
• One problem with the technique is
that it is difficult to predict how
much flattening will occur.
• Another problem is that some
patients are bothered by glare
following radial keratotomy, because
the slits apparently do not heal
evenly.
• lasix, or laser corneal sculpturing
is a laser surgery procedure in
which a thin portion of the cornea is
etched away to make the cornea less
convex.
• The advantage of this procedure is
that the results can be predicted
more accurately than can those of
radial keratotomy
• Hyperopia is farsightedness due to
the cornea and lens system is
optically too weak or the eyeball is
too short. The image is focused
behind the retina.
• Hyperopia can be corrected by
convex lenses that cause light rays to
converge as they approach the eye.
 • Presbyopia is the normal, presently
unavoidable degeneration of the
accommodation power of the eye
associated with aging. It occurs
because the lens becomes sclerotic
and less flexible.
• The eye is presbyopic when the near
point of vision has increased beyond
9 inches.
• The average age for the onset of
presbyopia is the mid 40s. Avid
readers and people who engage in
fine, close work may develop the
symptoms earlier.
• Presbyopia can be corrected by
wearing “reading glasses” for close
work and removing them to see at a
distance.
• Astigmatism is a type of refractive
error that affects the quality of focus.
If the cornea or lens is not uniformly
curved, the light rays do not focus at
a single point, but fall as a blurred
circle.
• Regular astigmatism can be
corrected by glasses formed with the
opposite curvature gradation.
• Color blindness results from the
dysfunction of one or more of the
three photopigments (red, green,
blue) involved in color vision.
• If one pigment is dysfunctional and
the other two are functional, the
condition is called dichromatism.
An example of dichromatism is red-
green color blindness
HEARING AND BALAN
CE
• The ear is divided into three sections:
external, middle and inner. Each of
these three sections is integral in the
process of hearing, and the inner ear
is also essential in the maintenance
of the sense of balance.
T H EE X T E R N A L E A R
• The auricle, or pinna, is the fleshy
part of the external ear on the
outside of the head; it consists
primarily of elastic cartilage covered
with skin. Its shape helps collect
sound waves and direct them toward
the external auditory canal.
• The external auditory canal is
• The external auditory canal (meatus)
is a short, S‐shaped, narrow passage
about 2.5 cm long and 0.6 cm wide,
which extends from the auricle to
the tympanic membrane. It is lined
with hairs and ceruminous glands,
which produce a yellow–brown
waxy cerumen, commonly called
earwax.
• Sound waves entering the external
auditory canal travel along until they
reach the tympanic membrane (ear
drum).
• Tympanic membrane (ear drum), a
thin translucent connective tissue
membrane covered by skin on its
external surface and internally by
mucosa, and shaped like a flattened
cone protruding into the middle ear.
• Sound waves that reach the tympanic
membrane make it vibrate, and this
vibration is transmitted to the bones
of the middle ear.
MIDDLE EAR
• Also known as the tympanic cavity,
this is a small, air‐filled cavity lined
with mucosa and contained within
the temporal bone. It is enclosed at
both ends, by the ear drum at the
lateral end and medially by a bony
wall with two openings, oval
(vestibular) window and round
(cochlear) window.
• Two additional openings provide air
passages from the middle ear.
 • One passage opens into the mastoid
air cells in the mastoid process of
the temporal bone. The other
passageway, the auditory tube, or
pharyngotympanic tube (also called
the eustachian tube), opens into the
pharynx and equalizes air pressure
between the outside air and the
middle ear cavity.
• Unequal pressure between the
middle ear and the outside
environment can distort the tympanic
membrane, dampen its vibrations,
and make hearing difficult.
Distortion of the tympanic
membrane, which occurs under these
conditions, also stimulates pain
fibers associated with it.
• The middle ear contains three
auditory ossicles:
1. the malleus (hammer) attaches at
three points to the inner surface of
the tympanic membrane;
2. the incus (anvil) attaches the malleus
to the stapes;
3. the stapes (stirrup) – the edges of the
base of the stapes are bound to the
edge of the oval window.
INNER EAR
• The inner ear is also known as the
labyrinth owing to the complicated
series of canals it contains. The
inner ear is composed of two main,
fluid‐filled parts:
• Bony labyrinth consists of tunnels
within the bone, that contain the
main organs of balance (the
semicircular canals and the
vestibule) and the main organ of
hearing (the cochlea)
• Membranous labyrinth – a series of
fluid‐filled sacs and tubes that are
contained within the bony labyrinth
• The bony labyrinth can be divided
into three parts.
1. The vestibule consists of a pair of
membranous sacs: the saccule and
the utricle. Receptors in these two
sacs provide the sensations of
gravity and linear acceleration.
2. The semicircular canals enclose
slender semicircular ducts.
Receptors in these ducts are
stimulated by the rotation of the
head. The combination of the
vestibule and the semicircular canals
is known as the vestibular complex.
3. The cochlea is a spiral‐shaped, bony
chamber that contains the cochlear
duct of the membranous labyrinth.
Receptors within this duct give us
the sense of hearing.
HEARING PROCESS
1. Sound travels in waves through air
and is funneled into ear by auricle.
2. Auricle through external auditory
meatus to tympanic membrane.
3. Tympanic membrane vibrates and
sound is amplified by malleus,
incus, stapes which transmit sound
to oval window.
4. Oval window produces waves in
perilymph of cochlea.
5. Vibrations of perilymph cause
vestibular membrane and
endolymph to vibrate.
6. Endolymph cause displacement of
basilar membrane.
7. Movement of basilar membrane is
detected by hair hairs in spiral organ.
8. Hair cells become bent and cause
action potential is created.
LOUD NOISESANDHE
ARING
LOSS
• Prolonged or frequent exposure to
excessively loud noises can cause
degeneration of the spiral organ at
the base of the cochlea, resulting in
high frequency deafness. For
example, loud music can impair
hearing.
EQUILIBRIUM
• The inner ear is responsible for
encoding information about
equilibrium (the sense of balance),
which it does in the vestibule and
semicircular canals, structures that
are sometimes collectively referred
to as the vestibular apparatus
• There are two types of equilibrium:
• Static (gravitational) equilibrium,
which involves the movement of the
head with respect to gravity
• Dynamic (rotational) equilibrium,
which involves acceleration of the
head in rotation, horizontal, and
vertical movements.
• Similar to the cochlea, the both the
vestibule and semicircular canals use
hair cells with stereocilia to detect
movement of fluid, in this case, in
response to changes in head position
or acceleration.
STATI C EQUILIBRI
UM
• The information for static
equilibrium and linear acceleration
(dynamic) comes from the utricle
and saccule within the vestibule.
The saccule and utricle each contain
a sense organ, called the macula,
where stereocilia and their
supporting cells are found. These
maculae are oriented 90 degrees to
one another so that they respond to
positions in different planes
• The organs can respond to changes
in position and acceleration because
the tips of their stereocilia project
into a dense otolithic membrane
made up of a mixture containing
granules of calcium and protein,
called otoliths.
• When the head moves, gravity
causes the otoliths to move. The
movement of the otoliths within the
membrane causes the stereocilia to
bend, initiating action potentials in
the vestibular nerve fibers that
innervate them
• This is how the body senses head
position and the linear
direction of acceleration is
determined by the specific pattern of
hair-cell activity across the maculae.
DYNAMICEQUILIBRIU
M
• The semicircular canals are three
ring-like extensions from the
vestibule and are mostly responsible
for dynamic equilibrium.
• At the base of each semicircular
canal, where it meets with the
vestibule is an enlarged region
known as the ampulla, which
contains a hair-cell containing
structure, called the crista ampullaris
that responds to rotational
movement.
• The stereocilia of the hair cells
extend into the cupula, a membrane
that attaches to the top of the
ampulla
• When the head rotates in a plane
parallel to the semicircular canal, the
fluid in the canal does not move as
quickly as the head is moving. This
pushes the cupula in the opposite
 direction, deflecting the stereocilia
and creating a nerve impulse.

• In each pair, deflection of the cupula

on one side of the body causes
depolarization of the hair cells while
the same movement causes
hyperpolarization of the hair cells on
the other side of the body.

SEA SICKNESS
• Seasickness is a form of motion
sickness, which consists of nausea,
weakness, and other dysfunctions
resulting from stimulation of the
semicircular canals during motion.

• Motion sickness can progress to

vomiting and incapacitation.

• It occurs because the brain

simultaneously perceives differing
sensory input from the semicircular
canals, eyes, and proprioceptors in
the lower limbs.

RESPIRATORY SYSTEM
FUNCTIONS OF THE
RESPIRATORY SYSTEM
• The respiratory system helps us 2in
what we commonly call breathing
but is more appropriately termed
respiration.
• Respiration includes four processes:
1. Ventilation
2. Externa respiration
3. The transport of oxygen and
carbon dioxide in the blood
4. Internal Respiration.
• Olfaction. The sensation of smell
occurs when airborne molecules are
drawn into the nasal cavity.
 • Protection. The respiratory system
provides protection against some
microorganisms by preventing them
from entering the body and
removing them from respiratory
surfaces.
CLASSIFICATION OF THE
RESPIRATORY SYSTEM
• There are two ways of classifying the
parts of the respiratory system:
structurally and functionally.
• Structurally, the respiratory system
is divided into the upper respiratory
tract and the lower respiratory tract.
FUNCTIONALLY, THE
RESPIRATORY SYSTEM IS
DIVIDED INTO TWO
REGIONS.
1. The conducting zone is exclusively
for air movement and extends from
the nose to the bronchioles.
2. The respiratory zone is within the
lungs and is where gas exchange
between air and blood takes place.
NOSE
• The external nose is the visible
structure that forms a prominent
feature of the face. The largest part
of the external nose is composed of
hyaline cartilage plates. The
bridge of the nose consists of the
nasal bones plus extensions of the
frontal and maxillary bones.
• The nasal cavity extends from the
nares to the choanae.
• The nares or nostrils, are the
external openings of the nasal
cavity, and the choanae are the
openings into the pharynx.
• The anterior part of the nasal cavity,
just inside each naris, is the
vestibule. The vestibule is lined
with stratified squamous epithelium,
which is continuous with the
stratified squamous epithelium of
the skin.
• The nasal septum is a partition
dividing the nasal cavity into right
and left parts.
FUNCTIONS OF THE NOSE
• Serves as a passageway for air
• Cleans the air: The vestibule is
lined with hairs, which trap some of
the large particles of dust in the air.
The mucous membrane lining the
nasal cavity consists of
pseudostratified ciliated columnar
epithelium with goblet cells
• Humidifies and warms the air:
Moisture from the mucous
epithelium and from excess tears that
drain into the nasal cavity added to
the air as it passes through the nasal
cavity. Warm blood flowing through
the mucous membrane warms the air
within the nasal cavity.
• Contains the olfactory epithelium.
located in the most superior part of
the nasal cavity
• Helps determine voice sound. The
nasal cavity and paranasal sinuses
are resonating chambers for speech.
PHARYNX
• The pharynx is the common
opening of both the digestive and
the respiratory systems. It receives
air from the nasal cavity and
receives air, food, and drink from
the oral cavity.
• Inferiorly, the pharynx is connected
to the respiratory system at the
larynx and to the digestive system at
the esophagus.
• The pharynx is divided into three
regions: the nasopharynx, the
oropharynx, and the laryngopharynx
NASOPHARYNX
• The nasopharynx is lined with a
mucous membrane containing
 pseudostratified ciliated columnar
epithelium with goblet cells.
• The posterior surface of the
nasopharynx contains the
pharyngeal tonsil, or adenoid,
which helps defend the body against
infection. An enlarged pharyngeal
tonsil can interfere with normal
breathing and the passage of air
through the auditory tubes.
OROPHARYNX
• The oropharynx extends from
the soft palate to the epiglottis. The
oral cavity opens into the
oropharynx through the fauces..
• Moist stratified squamous epithelium
lines the oropharynx and protects it
against abrasion.
• Two sets of tonsils, called the
palatine tonsils and the lingual
tonsils, are located near the fauces.
LARYNGOPHARYNX
• The laryngopharynx extends from
the tip of the epiglottis to the
esophagus and passes posterior to
the larynx.
• The laryngopharynx is lined with
moist stratified squamous
epithelium.
LARYNX
• The larynx is located in the anterior
part of the throat and extends from
the base of the tongue to the trachea.
It is a passageway for air between
the pharynx and the trachea.
• The larynx is connected by
membranes and/or muscles
superiorly to the hyoid bone
• The larynx consists of an outer
casing of nine cartilages connected
to one another by muscles and
ligaments. Six of the nine
cartilages are paired, and three are
unpaired.
• The single pieces of cartilage are the
thyroid cartilage, the epiglottis and
the cricoid cartilage.
• The thyroid cartilage is more
commonly known as the Adam’s
apple and, together with the cricoid
cartilage, protects the vocal cords.
• The cricothyroid ligament, which
connects the thyroid and cricoid
cartilage, is the landmark of an
emergency airway or tracheostomy
(McGrath, 2014).
• The epiglottis is a leaf‐shaped piece
of elastic cartilage attached to the
top of the larynx. Its function is to
protect the airway from food and
water.
• The paired arytenoid cartilages
articulate with the posterior,
superior border of the cricoid
cartilage.
• the paired corniculate cartilages
are attached to the superior tips of
the arytenoid cartilages.
• The paired cuneiform cartilages are
contained in a mucous membrane
anterior to the corniculate cartilages.
VESTIBULAR FOLDS
• The vestibular folds (false vocal
cords) consist of the vestibular
ligament covered by a mucous
membrane, and are pink in color.
• They are fixed folds, which act to
provide protection to the larynx.
VOCAL FOLDS
• The vocal folds, also known as
vocal cords, are composed of twin
infoldings of mucous membrane
stretched horizontally across the
larynx. The vocal folds and the
opening between them are called the
glottis.
 • They vibrate, modulating the flow of
air being expelled from the lungs
during phonation.
TRACHEA
• The trachea (or windpipe) is a
tubular vessel that carries air from
the larynx down towards the lungs.
• The outermost layer of the trachea
contains connective tissue that is
reinforced by a series of 16–20 C‐
shaped cartilage rings. The rings
prevent the trachea from collapsing
during an active breathing cycle.
• The trachea is also lined with
pseudostratified ciliated columnar
epithelium so that any inhaled debris
is trapped and propelled upwards
towards the esophagus and pharynx
to be swallowed or expectorated.
• The posterior wall of the trachea is
devoid of cartilage; it contains an
elastic ligamentous membrane and
bundles of smooth muscle called the
trachealis muscle.
• Contraction of the smooth muscle
can narrow the diameter of the
trachea.
CHOKING AND ASPIRATION
• Choking occurs when the airway is
obstructed by food, drink, or foreign
objects.
• Aspiration occurs when food, drink,
or foreign objects are breathed into
the lungs (going down the wrong
tube).
• It might happen during choking, but
aspiration can also be silent,
meaning that there is no outward
sign.
HEIMLICH MANEUVER
• Heimlich maneuver or abdominal
thrusts, are designed to force an
object out of the air passage by the
sudden application of pressure to
the abdomen.
INTUBATION
• Intubation is the placement of
endotracheal tube into the trachea to
maintain an open airway, or to serve
as a passage through which to
administer certain drugs.
• It is frequently performed in
critically injured, ill, or anesthetized
patients to facilitate ventilation of
the lungs
CRICOTHYROTOMY
• A cricothyrotomy is an incision
made through the skin and
cricothyroid membrane to establish
a patent airway during certain life-
threatening situations, such as
airway obstruction by a foreign
body, angioedema, or massive facial
trauma.
TRACHEOSTOMY
• Tracheostomy is an operation
performed to make an opening into
the trachea, commonly between the
second and third cartilage rings.
• Usually, the opening is intended to
be permanent, and a tube is inserted
into the trachea to allow airflow and
provide a way to remove secretions.
PRIMARY BRONCHI
• The primary bronchi or main
bronchi branch from the
trachea at The most inferior tracheal
cartilage forms a ridge called the
carina.
• The mucous membrane of the carina
is very sensitive to mechanical
stimulation, and materials reaching
the carina stimulate a powerful
cough reflex. Materials in the air
passageways inferior to the carina
do not usually stimulate a cough
reflex
TRACHEOBRONCHIAL TREE
 • The main bronchi divide into lobar
bronchi, or secondary bronchi,
within each lung.
• Two lobar bronchi exist in the left
lung, and three exist in the right
lung.
• The lobar bronchi, in turn, give rise
to segmental bronchi, or tertiary
bronchi.
• The bronchi continue to branch,
finally giving rise to bronchioles,
which are less than 1 mm in
diameter.
• The bronchioles also subdivide
several times to become even
smaller terminal bronchioles.
TERMINAL BRONCHIOLES
• The terminal bronchioles have no
cartilage, and the smooth muscle
layer is prominent. Relaxation and
contraction of the smooth muscle
within the bronchi and bronchioles
can change the diameter of the air
passageways and thereby change the
volume of air moving through them.
• The terminal bronchioles divide to
form respiratory bronchioles.
ALVEOLI
• Alveoli are small, air-filled
chambers where gas exchange
between the air and blood takes
place.
• The respiratory bronchioles give rise
to alveolar ducts, which are like
long, branching hallways with many
open doorways.
• The alveolar ducts end as two or
three alveolar sacs, which are
chambers connected to twoor more
alveoli
• Alveolar walls two basic epithelial
cell types:
1. Type I pneumocytes are thin
squamous epithelial cells
that form 90% of the alveolar
surface. Most of the gas
exchange between alveolar
air and the blood takes place
through these cells.
2. Type II pneumocytes are
round or cube-shaped
secretory cells that produce
surfactant, which makes it
easier for the alveoli to
expand during inspiration
RESPIRATORY MEMBRANE
• The respiratory membrane of the
respiratory zone in the lungs is
where gas exchange between the air
and blood takes place. It is formed
mainly by the alveolar walls and
surrounding pulmonary capillaries,
with some contribution by
respiratory bronchioles and alveolar
ducts. The respiratory membrane is
very thin to facilitate diffusion of
gases.
EMPHYSEMA
• Emphysema is a condition in which
lung alveoli become progressively
enlarged as the walls between them
are destroyed. Individuals who have
emphysema experience shortness of
breath and coughing.
• Cigarette smoking is the major risk
factor for emphysema.
LUNGS
• The lungs are the principal organs of
respiration, and on a volume basis
they are among the largest organs of
the body.
• Each lung is conical in shape, with
its base resting on the diaphragm
and its apex extending to a point
approximately 2.5 cm superior to the
clavicle.
• The right lung is larger than the left
and weighs an average of 620 g,
whereas the left lung weighs an
average of 560 g.
• The hilum is a region on the medial
surface of the lung where structures,
 such as the main bronchus, blood
vessels, nerves, and lymphatic
vessels, enter or exit the lung. All the
structures passing through the hilum
are referred to as the root of the
lung.
• The right lung has three lobes, and
the left lung has two and includes an
indentation called the cardiac notch.
• The lobes are separated by deep,
prominent fissures on the surface of
the lung, and each lobe is supplied
by a lobar bronchus.
• The lobes are subdivided into
bronchopulmonary segments, which
are supplied by the segmental
bronchi.
• The bronchopulmonary segments are
subdivided into lobules by
incomplete connective tissue walls.
The lobules are supplied by the
bronchioles.
PLEURAL MEMBRANES AND
CAVITIES
• Pleura: double-layered membrane
around lungs
• Parietal pleura: membrane
that lines thoracic cavity
• Visceral pleura: membrane that
covers lung’s surface
• Pleural cavity: space around each
lung.
MUSCLES OF RESPIRATION
• The muscles of inspiration include
the diaphragm, external intercostals,
pectoralis minor, and scalenes.
• Contraction of the diaphragm is
responsible for approximately two-
thirds of the increase in thoracic
volume during inspiration.
• The external intercostals, pectoralis
minor, and scalene muscles also
increase thoracic volume by
elevating the ribs.
• The muscles of expiration consist of
the muscles that depress the ribs and
sternum, such as the internal
intercostals and transverse thoracis,
which are assisted by the abdominal
muscles
RESPIRATION
• Respiration is the process by which
oxygen and carbon dioxide are
exchanged between the atmosphere
and body cells.
1. pulmonary ventilation
2. external respiration
3. transport of gases
4. internal respiration
PULMONARY VENTILATION
• Pulmonary ventilation describes the
process more commonly known as
• breathing.
• In order for air to pass in and out of
our lungs a change in pressure needs
to occur. Before inspiration the
intrapulmonary pressure, is the same
as atmospheric pressure.
• During inspiration the thorax
expands and the intrapulmonary
pressure falls below atmospheric
pressure. Because intrapulmonary
pressure is now less than
atmospheric pressure the air will
naturally enter our lungs until the
pressure difference no longer exists.
INSPIRATION
• Diaphragm descends and rib cage
expands
• Thoracic cavity volume increases,
pressure decreases
• Atmospheric pressure is greater than
(high) alveolar pressure (low)
• Air moves into alveoli (lungs)
EXPIRATION
• Diaphragm relaxes and rib cage
recoils
• Thoracic cavity volume decreases,
pressure increases
• Alveolar pressure is greater than
(high) atmospheric pressure (low)
 • Air moves out of lungs • The blood present in the
pulmonary artery has been
NERVOUS SYSTEM INFLUENCE collected from systemic
ON VENTILATION circulation and is therefore low
in oxygen and relatively high in
• Involuntary breathing results from
carbon dioxide.
stimulation of the respiratory center
1. Blood flow from lungs
in the medulla and the pons of the
through left side of heart to
brain.
tissue capillaries
• Central chemical receptors in the
2. Oxygen diffuses from
medulla indirectly monitor the level
capillaries into interstitial
of carbon dioxide in the blood.
fluid because Po2 in
Carbon dioxide exerts the main
interstitial fluid is lower than
influence on breathing.
capillary
• Peripheral chemical receptors in the
3. Oxygen diffuses from
aorta and carotid arteries monitor
interstitial fluid into cells
the level of oxygen in the blood.
(Po2) is less
When oxygen levels drop,
respiratory rate and depth increase to CARBON DIOXIDE TRANSPORT
improve the blood oxygen level. AND BLOOD PH
RESPIRATORY RATE AND • CO2 diffuses from cells into
RHYTHM capillaries
• CO2 enters blood and is transported
• In health, an adult’s respiratory rate
in plasma, combined with blood
is normally between 12 and 20
proteins, bicarbonate ions
respirations per minute and
• CO2 reacts with water to form
autonomic and involuntary.
carbonic acid
• Tachypnea
• CO2 + H2O H2CO3
• Bradypnea
• bicarbonate ions dissociate into a
• A regular rhythm means that the
hydrogen ion and a bicarbonate ion
frequency of the respiration follows
• H2CO3 H+ + HCO3-
an even tempo with equal intervals
• Carbonic anhydrase (RBC) increases
between each respiration.
rate of CO2 reacting with water
• CO2 levels increase blood pH
decreases
DIFFUSION OF GASES IN
LUNGS HYPOXIA
• Hypoxia is defined as a lack of
• External respiration only occurs
oxygen within body tissues.
beyond the respiratory
bronchioles. External respiration HYPOXEMIA
is the diffusion of oxygen from
the alveoli into pulmonary • Hypoxia is defined as a lack of
circulation and the diffusion of oxygen within body tissues.
carbon dioxide in the opposite
direction. OXYGEN
• Each lobule of the lung has its
• Oxygen is used to treat hypoxemia,
own arterial blood supply.
not breathlessness.
 • The aim of oxygen therapy is to
maintain a normal or near‐normal
oxygen saturation level and that this
should be achieved on the lowest
possible concentration of oxygen.
• the target oxygen saturation levels
for acutely ill adults are 94–98% and
88–92% for those at risk of
hypercapnic (excess carbon dioxide)
failure – that is, patients living with
chronic obstructive pulmonary
disease.
RESPIRATORY DISEASES
• Pneumonia is an inflammation of the
lung parenchyma caused by various
microorganisms, including bacteria,
mycobacteria, fungi, and viruses.
• If a substantial portion of one or
more lobes is involved, the disease
is referred to as lobar pneumonia.
• The term bronchopneumonia is used
to describe pneumonia that is
distributed in a patchy fashion,
having originated in one or more
localized areas within the bronchi
and extending to the adjacent
surrounding lung parenchyma.
CLASSIFICATION OF
PNEUMONIA
1. community-acquired pneumonia
(CAP)
2. hospital-acquired (nosocomial)
3. pneumonia in the
immunocompromised host
4. aspiration pneumonia
PATHOPHYSIOLOGY OF
PNEUMONIA
• hypoventilation, a ventilation–
perfusion mismatch occurs in the
affected area of the lung occur.
• Venous blood entering the
pulmonary circulation passes
through the underventilated area and
travels to the left side of the heart
poorly oxygenated. The mixing of
oxygenated and unoxygenated or
poorly oxygenated blood eventually
results in arterial hypoxemia.
CLINICAL MANIFESTATIONS
1. Fever
2. Dyspnea and tachypnea
3. Rales
4. Cough and sputum production
5. Pleuritic chest pain
6. Chest X-ray confirmation
ASTHMA
• Asthma is a chronic inflammatory
disease of the airways that causes
airway hyperresponsiveness,
mucosal edema, and mucus
production.
• This inflammation ultimately leads
to recurrent episodes of asthma
symptoms: cough, chest tightness,
wheezing, and dyspnea.
PATHOPHYSIOLOGY OF
ASTHMA
• Neuromechanisms (Autonomic
Nervous System):
• Stimulation of the vagus nerve
(which is responsible for
bronchomotor tone) by viral
respiratory infections, air pollutants,
and other stimuli causes
bronchoconstriction, increased
secretion of mucus, and dilation of
the pulmonary vessels.
• Antigen-Antibody Reaction
• Susceptible individuals form
abnormally large amounts of IgE
when exposed to certain allergens.
• IgE fixes itself to the mast cells of
the bronchial mucosa.
• The resulting antigen combines with
the cell-bound IgE molecules,
causing the mast cell to degranulate
and release chemical mediators.
• Chemical mediators act on bronchial
smooth muscle to cause
bronchoconstriction, reduce
 mucociliary clearance, on bronchial
glands to cause mucus secretion, on
blood vessels to cause vasodilation
and increased permeability, and on
leukocytes to cause a cellular
infiltration and inflammation.
• Late-phase reactions (these occur 4
to 8 hours after the initial response)
include the influx of eosinophils,
neutrophils, lymphocytes, and
monocytes.
• Bronchial Inflammation
CLASSIFICATION OF ASTHMA
• Extrinsic Asthma: Hypersensitivity
reaction to inhalant allergens.
Mediated by immunoglobulin E (IgE
mediated).
• Intrinsic Asthma: No inciting
allergen. Infection, typically
viral. Environmental stimuli (such as
air pollution).
• Aspirin-induced Asthma: Induced by
ingestion of aspirin and related
compounds
• Exercise-induced Asthma:
Symptoms vary from slight chest
tightness and cough to severe
wheezing and cough and shortness
of breath that usually occurs after 5
to 20 minutes of sustained exercise.
CLINICAL MANIFESTATIONS
• Episodes of coughing
• Wheezing
• Dyspnea
• Feeling of chest tightness
TREATMENT:
• Long-term Controllers:
• Inhaled corticosteroids (ICSs), such
as triamcinolone (Azmacort), and
budesonide (Pulmicort).
• Oral corticosteroids (maintenance
dose).
• Quick-relief Medications:
• Short-acting bronchodilators by
inhalation: such as albuterol
(salbutamol, Ventolin)
PULMONARY TUBERCULOSIS
• Tuberculosis (TB) is an infectious
disease that primarily affects the
lung parenchyma. It also may be
transmitted to other parts of the
body, including the meninges,
kidneys bones, and lymph nodes.
The primary infectious agent,
M.tuberculosis.
• TB spreads from person to person by
airborne transmission.
PATHOPHYSIOLOGY OF TB
• TB begins when a susceptible person
inhales mycobacteria and becomes
infected. The bacteria are transmitted
through the airways to the alveoli,
where they are deposited and begin
to multiply.
• The bacilli also are transported via
the lymph system and bloodstream
to other parts of the body (kidneys,
bones, cerebral cortex) and other
areas of the lungs (upper lobes).
• The body’s immune system responds
by initiating an inflammatory
reaction. Phagocytes (neutrophils
and macrophages) engulf many of
the bacteria, and TB- specific
lymphocytes lyse (destroy) the
bacilli and normal tissue.
• This tissue reaction results in the
accumulation of exudate in the
alveoli, causing bronchopneumonia.
The initial infection usually occurs 2
to 10 weeks after exposure.
• Granulomas, new tissue masses of
live and dead bacilli, are surrounded
by macrophages, which form a
protective wall. They are then
transformed to a fibrous tissue mass
which is called a Ghon tubercle.
• The material (bacteria and
macrophages) becomes necrotic,
forming a cheesy mass. This mass
 may become calcified and form a
collagenous scar. At this point, the
bacteria become dormant, and there
is no further progression of active
disease.
• After initial exposure and infection,
active disease may develop because
of a compromised or inadequate
immune system response.
• Active disease also may occur with
reinfection and activation of dormant
bacteria.
• In this case, the Ghon tubercle
ulcerates, releasing the cheesy
material into the bronchi. The
bacteria then become airborne,
resulting in further spread of the
disease.

CLINICAL MANIFESTATIONS
• Low-grade fever
• Cough,
• Night sweats
• Fatigue and weight loss.
• Hemoptysis

TREATMENT
• A combination of drugs to which the
organisms are susceptible is given to
destroy viable bacilli as rapidly as
possible and to protect against the
emergence of drug resistant
organisms.
•