Thorax - Respiratory Clinicals

Sternum The sternum is a common site for bone marrow

biopsy because it possesses hematopoietic
marrow throughout life and because of its
breadth and subcutaneous position, It may be
split in the median plane (median sternotomy) to
allow the surgeon to gain easy access to the
lungs, heart, and great vessels.
Thoracic Outlet Syndrome Thoracic outlet syndrome is the compression of
neurovascular structures in the thoracic outlet
(a space between the clavicle and the first rib),
causing a combi- nation of pain, numbness,
tingling, or weakness and fatigue in the upper
limb caused by pressure on the brachial plexus
(lower trunk or C8 and T1 nerve roots) by a
cervical rib (mesenchymal or carti- laginous
elongation of the transverse process of the
seventh cervical vertebra). A cervical rib may
also compress the subclavian artery in the
thoracic outlet, resulting in ischemic muscle
pain in the upper limb. Compression on the
neurovascular bundle occurs as a result of
cervical ribs or abnormal insertions of the
anterior and middle scalene muscles.
Flail Chest Flail chest is a loss of stability of the thoracic
cage that occurs when a segment of the anterior
or lateral thoracic wall moves freely because of
multiple rib fractures, allowing the loose
segment to move inward on inspiration and
outward on expiration. Flail chest is an
extremely painful injury and impairs ventilation,
thereby affecting oxygenation of the blood and
causing respiratory failure.
Rib Fractures Fracture of the first rib may injure the brachial
plexus and subclavian vessels. The middle ribs are
most commonly fractured and usually result
from direct blows or crushing injuries. The
broken ends of ribs may cause pneumothorax and
lung or spleen injury. Lower rib fractures may
tear the diaphragm, resulting in a diaphragmatic
hernia.
Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is a
group of lung diseases associated with chronic
obstruction of airflow through the airways and
lungs. It consists of chronic bronchitis and
emphysema, which are the most common forms
and is caused primarily by cigarette smoking.
Symptoms of COPD include chronic cough,
difficulty in breathing, chronic sputum
production, and wheezing. It is treated with
bronchodilators and glucocorticoids.
Chronic Bronchitis Chronic bronchitis is an inflammation of the
airways, which result in excessive mucus
production that plugs up the airways, causing a
cough and breathing difficulty.
Emphysema Emphysema is an accumulation of air in the
terminal bronchioles and alveolar sacs (air is
trapped in the lungs) due to destruction of the
alveolar walls, reducing the surface area available
for the exchange of oxygen and carbon dioxide
and thereby reducing oxygen absorption.
Barrel Chest Barrel chest is a chest resembling the shape of a
barrel, with increased anteroposterior diameter
that occurs as a result of long-term
overinflation of the lungs, sometimes seen in
cases of emphysema or asthma
Asthma Asthma is a chronic inflammation of the bronchi
that causes swelling and narrowing
(constriction) of the airways. It causes an
airway obstruction and is characterized by
dyspnea (difficulty in breathing), cough, and
wheezing because of spasmodic contraction of
smooth muscles in the bronchioles.
Bronchiectasis Bronchiectasis is a chronic dilation of bronchi
and bronchioles resulting from destruction of
bronchial elastic and muscular elements, which
may cause collapse of the bronchioles. It may be
caused by pulmonary infections (e.g., pneumonia,
tuberculosis [TB]) or by a bronchial obstruction
with heavy sputum production. Signs and
symptoms include a chronic cough with
expectoration of large volumes of sputum. COPD
may include asthma and bronchiectasis.
Pleurisy Pleurisy (pleuritis) is an inflammation of the
pleura with exudation (escape of fluid from blood
vessels) into its cavity, causing the pleural
surfaces to be roughened. This roughening
produces friction, and a pleural rub can be heard
with the stethoscope on respiration. The
exudate forms dense adhesions between the
visceral and parietal pleurae, form- ing pleural
adhesions. Symptoms are a chill, followed by
fever and dry cough. Treatments consist of
relieving pain with analgesics, as necessary, and
lidocaine for intercostal nerve block.
Pneumothorax Pneumothorax is an accumulation of air in the
pleural cavity, and thus, the lung collapses
because the negative pressure necessary to keep
the lung expanded has been eliminated. It results
from an injury to the thoracic wall or the lung.
Tension Pneumothorax Tension pneumothorax is a life-threatening
pneumothorax in which air enters during
inspiration and is trapped during expi- ration;
therefore, the resultant increased pressure
displaces the mediastinum to the opposite side,
with consequent cardiopulmonary impairment.
Major symptoms of pneumothorax are chest pain
and dyspnea (shortness of breath). It can be
treated by draining the pleural air collection by
simple aspi- ration using an intravenous
catheter or chest tube thoracostomy.

Pleural effusion Pleural effusion is an abnormal accumulation of

excess fluid in the pleuralspace. There are two
types of pleural effusion: the transudate (clear
watery fluid) and the exudate (cloudy viscous
fluid). A transudate is caused by congestive heart
failure or, less commonly, liver or kidney disease,
whereas an exudate is caused by inflammation,
pneumonia, lung cancer, TB, asbestosis, or
pulmonary embolism. Symptoms include shortness
of breath, chest pain, and cough. It can be
treated by removing fluid by thoracentesis.
Thoracentesis Thoracentesis (pleuracentesis or pleural tap) is a
surgical puncture of the thoracic wall into the
pleural cavity for aspiration of fluid. An
accumulation of fluid in the pleural cavity has a
clinical name such as a hydrothorax (water), a
hemothorax (blood), a chylothorax (lymph), and a
pyothorax (pus). It is performed at or posterior
to the midaxillary line one or two intercostal
spaces below the fluid level but not below the
ninth intercostal space. The ideal site is seventh,
eighth, or ninth intercostal space, and this site
avoids possible accidental puncture of the lung,
liver, spleen, and diaphragm. A needle should be
inserted immediately above the superior mar- gin
of a rib to avoid injury to the intercostal
neurovascular bundle.
Pneumonia Pneumonia (pneumonitis) is an inflammation of
the lungs, which is of bacterial and viral origin.
Symptoms are usually cough, fever, sputum
production, chest pain, and dyspnea. It can be
treated by administering antibiotics for initial
therapy.
Tuberculosis TB is an infectious lung disease caused by the
bacterium Mycobacterium tuberculosis and is
characterized by the formation of tubercles
that can undergo caseous necrosis. Its symptoms
are cough, fever, sweats, tiredness, and
emaciation. TB is spread by coughing and mainly
enters the body in inhaled air and can be treated
with very effective drugs.
Pancoast’s tumour Pancoast’s or superior pulmonary sulcus tumor is
a malignant neoplasm of the lung apex and causes
Pancoast’s syndrome, which comprises (a) lower
trunk bra- chial plexopathy (which causes severe
pain radiating toward the shoulder and along the
medial aspect of the arm and atrophy of the
muscles of the forearm and hand) and (b) lesions
of cervical sympathetic chain ganglia with
Horner’s syndrome (ptosis, enophthalmos, miosis,
anhidrosis, and vasodilation).
Superior Pulmonary Sulcus Superior pulmonary sulcus is a deep vertical
groove in the posterior wall of the thoracic
cavity on either side of the vertebral column
formed by the posterior curvature of the ribs,
lodging the pos- terior bulky portion of the lung.
Pulmonary edema Pulmonary edema involves fluid accumulation and
swelling in the lungs caused by lung toxins
(causing altered capillary permeability), mitral
stenosis, or left ventricular failure that results
in increased pressure in the pulmonary veins. As
pressure in the pulmonary veins rises, fluid is
pushed into the alveoli and becomes a barrier to
normal oxygen exchange, resulting in shortness
of breath. Signs and symptoms include rapid
breathing, increased heart rate, heart murmurs,
shortness of breath, difficulty breathing, cough,
and excessive sweating. Treatments include
supplemental oxygen, bed rest, and mechanical
ventilation.

Asbestosis Asbestosis is caused by inhalation of asbestos

fibers, and accumulated particles and fibers in
the lungs can cause irritation and inflammation,
leading to a breathing disorder, cough, chest
pains, and a high risk of lung cancer.
Mesothelioma Mesothelioma is a rare form of cancer that is
caused by previous exposure to asbestos and is
found in the mesothelium primarily in the
pleura. Its symptoms include shortness of breath
due to pleural effusion, chest wall pain, cough,
fatigue, and weight loss.

Atelectasis Atelectasis is the collapse of a lung by blockage

of the air passages or by very shallow breathing
because of anesthesia or prolonged bed rest. It is
caused by mucus secretions that plug the airway,
foreign bodies in the airway, and tumors that
compress or obstruct the airway. Signs and
symptoms are breathing difficulty, chest pain,
and cough.
Lung Cancer Lung cancer has two types, small cell and non-
small cell carcinomas, based on histology of the
cell type of origin. Small cell carcinoma accounts
for 20% and grow aggressively, while non-small
cell carcinoma (80%) is divided further into
squamous cell carcinoma, adenocarcinoma, and
bronchioalveolar large cell carcinoma. Its
symptoms include chronic cough, coughing up
blood, shortness of breath, chest pain, and
weight loss.

Pulmonary Embolism Pulmonary embolism (pulmonary

Lesion of the phrenic nerve
Hiccup
thromboembolism) is an obstruction of the
pulmonary artery or one of its branches by an
embolus (air, blood clot, fat, tumor cells, or
other foreign material), which arises in the deep
veins of the lower limbs or in the pelvic veins or
occurs following an operation or after a
fracture of a long bone with fatty marrow.
Symptoms may be sudden onset of dyspnea,
anxiety, and substernal chest pain. Treatments
include heparin therapy and surgical therapy such
as pulmonary embolectomy, which is surgical
removal of massive pulmonary emboli.
Lesion of the phrenic nerve may or may not
produce complete paralysis of the corresponding
half of the diaphragm because the accessory
phrenic nerve, derived from the fifth cervical
nerve as a branch of the nerve to the subclavius,
usually joins the phrenic nerve in the root of
the neck or in the upper part of the thorax.
Hiccup is an involuntary spasmodic sharp
contraction of the diaphragm, accompanied by
the approximation of the vocal folds and closure
of the glottis of the larynx. It may occur as a
result of the stimulation of nerve endings in the
digestive tract or the diaphragm. When chronic,
it can be stopped by sectioning or crushing the
phrenic nerve.
Nerves and Blood Vessels of the Thoracic Wall:
A. Intercostal Nerves
• Are the anterior primary rami of the first 11 thoracic spinal nerves. The anterior
primary ramus of the 12th thoracic spinal nerve is the subcostal nerve, which runs
beneath the 12th rib. Run between the internal and innermost layers of muscles, with
the intercostal veins and arteries above (veins, arteries, nerves [VAN]). Are lodged in
the costal grooves on the inferior surface of the ribs.
Give rise to lateral and anterior cutaneous branches and muscular branches.

B. Internal Thoracic Artery

Usually arises from the first part of the subclavian artery and descends directly behind
the first six costal cartilages, just lateral to the sternum. Gives rise to two anterior
intercostal arteries in each of the upper six intercostal spaces and terminates at the sixth
intercostal space by dividing into the musculophrenic and superior epigastric arteries.

1. Pericardiophrenic Artery
Accompanies the phrenic nerve between the pleura and the pericardium to the diaphragm.
Supplies the pleura, pericardium, and diaphragm (upper surface).

2. Anterior Intercostal Arteries

Are 12 small arteries, two in each of the upper six intercostal spaces that run laterally,
one each at the upper and lower borders of each space. The upper artery in each intercostal
space anastomoses with the posterior intercostal artery, and the lower one joins the
collateral branch of the posterior intercostal artery.
Provide muscular branches to the intercostal, serratus anterior, and pectoral muscles.

3. Anterior Perforating Branches

Perforate the internal intercostal muscles in the upper six intercostal spaces, course with
the anterior cutaneous branches of the intercostal nerves, and supply the pectoralis major
muscle and the skin and subcutaneous tissue over it.
Provide the medial mammary branches (second, third, and fourth branches).

4. Musculophrenic Artery
Follows the costal arch on the inner surface of the costal cartilages.
Gives rise to two anterior arteries in the 7th, 8th, and 9th spaces; perforates the dia-
phragm; and ends in the 10th intercostal space, where it anastomoses with the deep
circumflex iliac artery.
Supplies the pericardium, diaphragm, and muscles of the abdominal wall.
5. Superior Epigastric Artery
Descends on the deep surface of the rectus abdominis muscle within the rectus sheath;
supplies this muscle and anastomoses with the inferior epigastric artery.
Supplies the diaphragm, peritoneum, and anterior abdominal wall.

C. Internal Thoracic Vein

• Is formed by the confluence of the superior epigastric and musculophrenic veins, ascends
on the medial side of the artery, receives the upper six anterior intercostal and
pericardiacophrenic veins, and ends in the brachiocephalic vein.

D. Thoracoepigastric Vein
• Is a venous connection between the lateral thoracic vein and the superficial epigastric
vein.

Lymphatic drainage of the thorax:

A. Sternal/Parasternal (Internal Thoracic) Nodes

• Are placed along the internal thoracic artery
• Receive lymph from the medial portion of the breast, intercostal spaces, diaphragm and
supra umbilical region of the abdominal wall.
• Drain into the junction of the internal jugular and subclavian veins

B. Intercostal Nodes:
• Lie near the heads of the ribs
• Receive lymph from the intercostal spaces and pleura
• Drain into the cisterna chyli of the thoracic duct

C. Phrenic Nodes:
• Lie on the thoracic surface of the diaphragm.
• Receive lymph from the pericardium, diaphragm, and liver
• Drain into the sternal and posterior mediastinal nodes.
Lymphatic drainage of the lungs

• Drain the bronchial tree, pulmonary vessels, and connective tissue septa.

• Run along the bronchiole and bronchi toward the hilus, where they drain to the pulmonary
(intrapulmonary) and then bronchopulmonary nodes, which in turn drain to the inferior
(carinal) and superior tracheobronchial nodes, the tracheal (paratracheal) nodes,
bronchomediastinal nodes and trunks, and eventually to the thoracic duct on the left and
right lymphatic duct on the right.

• Are not present in the walls of the pulmonary alveoli.

Blood vessels of the Lungs

A. Pulmonary Artery

• Extends upward from the conus arteriosus of the right ventricle of the heart and carries
poorly oxygenated blood to the lungs for oxygenation.

• Passes superiorly and posteriorly from the front of the ascending aorta to its left side for
approximately 5 cm and bifurcates into the right and left pulmonary arteries within the
concavity of the aortic arch at the level of the sternal angle.

• Has much lower blood pressure than that in the aorta and is contained within the fibrous
pericardium.

•
1. Left Pulmonary Artery

• Carries deoxygenated blood to the left lung, is shorter and narrower than the right
pulmonary artery, and arches over the left primary bronchus.

• Is connected to the arch of the aorta by the ligamentum arteriosum, the fibrous
remains of the ductus arteriosus.

2. Right Pulmonary Artery

• Runs horizontally toward the hilus of the right lung under the arch of the aorta
behind the ascending aorta and SVC and anterior to the right bronchus.
B. Pulmonary Veins

• Are intersegmental in drainage (do not accompany the bronchi or the segmental artery
within the parenchyma of the lungs).

• Leave the lung as five pulmonary veins, one from each lobe of the lungs. However, the
right upper and middle veins usually join so that only four veins enter the left atrium.

• Carry oxygenated blood from the respiratory part (alveoli) of the lung and deoxygenated
blood from the visceral pleura and from a part of the bronchioles to the left atrium of
the heart. (Gas exchange occurs between the walls of alveoli and pulmonary capillaries,
and the newly oxygenated blood enters venules and then pulmonary veins.)

C. Bronchial Arteries

• Arise from the thoracic aorta; usually there is one artery for the right lung and two for
the left lung.

• Supply oxygenated blood to the nonrespiratory conducting tissues of the lungs and the
visceral pleura. Anastomoses occur between the capillaries of the bronchial and pulmonary
systems.

D. Bronchial Veins

• Receive blood from the bronchi and empty into the azygos vein on the right and into
the accessory hemiazygos vein or the superior intercostal vein on the left.

• May receive twigs (small vessels) from the tracheobronchial lymph nodes.
Nerve supply to the lung

Phrenic Nerve

Arises from the third through fifth cervical nerves (C3–C5) and lies in front of the
anterior scalene muscle.

▪ Enters the thorax by passing deep to the subclavian vein and superficial to the
subclavian arteries.

▪ Runs anterior to the root of the lung, whereas the vagus nerve runs posterior to the
root of the lung.

▪ Is accompanied by the pericardiophrenic vessels of the internal thoracic vessels and

descends between the mediastinal pleura and the pericardium.

▪ Innervates the fibrous pericardium, the mediastinal and diaphragmatic pleurae, and
the diaphragm for motor and its central tendon for sensory.

Pulmonary Plexus

▪ Receives afferent and efferent (parasympathetic preganglionic) fibers from the

vagus nerve, joined by branches (sympathetic postganglionic fibers) from the
sympathetic trunk and cardiac plexus.

▪ Is divided into the anterior pulmonary plexus, which lies in front of the root of the
lung, and the posterior pulmonary plexus, which lies behind the root of the lung.

▪ Has branches that accompany the blood vessels and bronchi into the lung.

▪ Has sympathetic nerve fibers that dilate the lumina of the bronchi and constrict
the pulmo- nary vessels, whereas parasympathetic fibers constrict the lumina,
dilate the pulmonary vessels, and increase glandular secretion.