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ANATOMI SISTEM RESPIRASI

Sasanthy Kusumaningtyas
Departemen Anatomi
FKUI
TOPIK
• Saluran nafas atas
• Hidung
• Pharynx
• Larynx dan topografinya
• Saluran nafas bawah
• Trachea
• Bronchus
• Paru-paru, dan topografinya
• Aspek anatomi klinis sistem respirasi
Fungsi umum sistem respirasi
Mengambil O2 dari udara dan memasukkannya ke dalam darah, serta
mengeluarkan CO2 dari dalam darah ke udara

Transport gas ke
dan dari paru-paru bernafas
& jaringan
STRUKTUR??

Respirasi Respirasi • Saluran nafas (atas dan bawah)


internal eksternal • Otot-otot
Nares
Nares externa

Source; Elaine N Marieb, Patricia


Brady Wilhelm, & Jon Mallat. Human
Anatomy. 6 th ed media update.
Benjamin Cummings. 2012
Cavum nasi
(rongga hidung)
• Membentang mulai dari
nostril/nares (apertura nasi
anterior) – choanae
(apertura nasi posterior/
nares interna)
• Septum nasi memisahkan
cavum nasi menjadi 2
bagian.
• Dinding medial dan lateral
Cavum nasi (rongga hidung)
Rangka hidung

Rangka cavum nasi terdiri


atas:
• 1 tulang: ethmoid,
sphenoid, frontal and
vomer;
• 1 pasang tulang:
nasal, maxillaris,
palatina, lacrimal,dan
conchae nasalis
inferior.
Cavum nasi (rongga hidung)
Dinding medial
• Anterior: cartilago septi nasi;
• Posterior: vomer dan lamina
perpendicularis os ethmoidalis
Lantai: proccesus palatinus os maxillaris
dan pars horizontalis os palatinum
Atap: corpus os sphenoid, lamina
cribriformis os ethmoid, os frontal, os
nasal dan cartilago nasalis
Cavum nasi (rongga hidung)
Dinding lateral
• Os ethmoidalis dan processus
uncinatus
• Lamina perpendicular os palatina
• Pars medial processus pterigoideus
os sphenoid
• Permukaan medial os lacrimal dan
maxilla
• Concha nasalis inferior

• Struktur:
• Conchae
• Meatus nasi
• Muara sinus paranasalis
Cavum nasi (rongga hidung)

Sinus paranasalis
• Sinus frontalis
• Sinus sphenoidalis
• Sinus ethmoidales: anterior,
media, posterior
• Sinus maxillaris
Cavum nasi (rongga hidung)
Muara sinus paranasalis
Sinus
• sinus sphenoidalis: recessus spheno-ethmoidalis
• sinus ethmoidalis posterior: meatus superior
• sinus ethmoidalis anterior: infundibulum
• sinus ethmoidalis media: bula ethmoidalis
• sinus maxillaris: hiatus semilunaris pada meatus
media
Cavum nasi (rongga hidung)
Sinus
paranasalis
Innervasi
• Sensorik khusus : N.I untuk penghidu
• Sensorik umum: bagian anterior N.V1 (ophthalmicus); bagian posterior
hidung oleh N.II (maxillaris).
• Persarafan simpatis: ganglion simpaticus cervicalis superior.
Apa yang terjadi?
Dimanakah letaknya?
Pembuluh darah apa yang terlibat?
Vaskularisasi
• Terutama oleh a. maxillaris dn cabang-cabangnya.
• Anastomosis di area Kiesselbach: a. sphenopalatina -- r. septalis a.
labialis superior (cabang dari a. facialis) di daerah vestibulum
epistaxis
• Venanya membentuk plexus submucosal
Pharynx
Dibagi 3 bagain:
Nasopharynx.
Oropharynx.
Laryngopharynx
Membuka ke
esophagus
setinggi VC VI.
Pharynx

Nasopharynx

Batas Oropharynx dengan rongga


mulut: isthmus faucium
Source; Anne M. Gilroy, et al. Atlas of
Anatomy. Thieme. 2009
Infeksi pada tonsilla pharyngea (adenoitis) dapat menyebabkan obstruksi pada jalan nafas dari choane
menuju nasopharynx.
Larynx
• Adalah struktur muskuloligamen berongga dengan kerangka tulang
rawan.
• Kerangka larynx: cartilago thyroidea, cricoidea, arytenoidea (2),
corniculata (2), cuneiforme (2), tricea (2) dan epiglottis
• Pintu masuk larynx: glottis, batas:
• Anterior: epiglottis
• Lateral: plica aryepiglottica
• Posterior: membran mucosa yang membentang antara
cartilago arytenoid
Kerangka larynx

Source; Anne M. Gilroy, et al. Atlas of Anatomy. Thieme. 2009


Kerangka larynx

Source; Anne M. Gilroy, et al. Atlas of


Anatomy. Thieme. 2009
Larynx: kerangka cartilago
Ligamen
Ekstrinsik:
• Membrana thyrohyoid
• Lig. hyoepigloticus
• Lig. cricotrachealis
Ligamen
Intrinsik
• Lig.cricothyroideus
(membrana
cricovoccalis/cricothyroid),ke
arah anterior menebal
membentuk
lig.cricothyroideum
medianum. Tepi bebas
lig.cricothyroideus menebal
membentuk lig.voccale.
• Membrana quadrangularis
Ligamen

Intrinsik
• Membrana quadrangular
• Mulai dari tepi lateral
epiglottis – permukaan
anterolateral arythenoid dan
corniculata.
• Tepi bebas bagian bawahnya
menebal membentuk
lig.vestibularis
Larynx
Struktur bagian dalam
larynx:
• Plica vestibulairis
• Plica vocalis
• Ventriculus laryngis
Morgagnii
• Rima glottidis & rima
vestibuli
• Conus elaticus
(ligament
cricothyroidea)
Laringoskopi
Otot-otot intrinsik larynx
• M.cricoarytenoideus: posterior & lateralis
• M.cricothyroideus, pars recta & pars obliquus
• M.arytenoideus, pars transversa & pars obliquus
• M.voccalis
• M.thyroarytenoideus
Otot-otot intrinsik larynx

m.arythenoideus
transversus m.voccalis

m.arythenoideus
obliquus
m.crico
thyroideus m.crico
arythenoideus
posterior
m.crico
arythenoideus
lateralis
m.aryepiglottica

m.thyroarythenoideus
Otot-otot intrinsik larynx
Otot Fungsi Persarafan

M. cricothyroideus (pars menegangkan pita suara r.exterunus


n.laryngeus
oblique dan pars recta) superior n.X

M. cricoarytenoideus lateral  Aduksi plica voccalis; rotasi interna n. laryngeus


inferior cabang
M. cricoarytenoideus abduksi pita suara akhir dari
posterior n.laryngeus
reccurens n.X
M. arytenoideus (pars , aduksi plica voccalis, mengecilkan
oblique dan pars tranversa) rima glottidis dan menutup bagian
posterior rima glottidis
M. vocalis Mengatur tegangan pada plica voccalis
(thyroarytenoideus)
Kerja otot-otot larynx
Anatomi
permukaan larynx
Anatomi
permukaan larynx
Topografi larynx
Aspek anterior
• Terletak pada trigonum
anterior.
• Tertutup oleh otot-otot
“strap muscles”
Topografi larynx
Kelenjar thyroid
• Setinggi C5-T1 vertebra
• Memiliki isthmus,
biasanya menutupi cincin
trachea 2-3
• Suplai darah: a.thyroidea
superior, inferior, a.
thyroidea ima (10%). a.
thyroidea ima umumnya
mencapai isthmus
Topografi larynx

a.thyroidea ima
Topografi larynx
Kelenjar parathyroid
Neurovaskular
larynx
Semua otot-otot
intrinsik laring
diinnervasi oleh
n.laryngeus
recurens, kecuali
m. crico
thyroideus, oleh n.
laryngeus externus

Vaskularisasi:
a. laryngea
superior dan
inferior
Larynx
• Cidera n,laryngeus inferior  paralisis plica voccalis, mungkin terjadi
pada prosedur thyroidectomy
• Tracheostomy
• Golden rule  “stick exactly to the midline”
Larynx
• Cricothyroidotomy/ cricothyrotomi/emergency airway puncture:
prosedur inisisi membrana cricothyroid untuk membuat jalan udara ke
dalam laring udara
• A tracheostomy is a procedure in which a hole is made in the trachea and a tube is
inserted to enable ventilation.
• In the emergency situation a tracheostomy is typically performed when there is
obstruction to the larynx, either due to inhalation of a foreign body, severe edema
secondary to anaphylactic reaction, or severe head and neck trauma.
• In the emergency situation the cricothyroid ligament can be identified by simple
palpation and a small needle can be inserted to establish an airway. The typical
situation in which a tracheostomy is performed is in the calm atmosphere of an
operating theater. A small transverse incision is placed in the lower third of the neck
anteriorly. The strap muscles are deviated laterally and the trachea can be easily
visualized. Occasionally it is necessary to divide the isthmus of thyroid gland. An
incision is made in the second and third tracheal rings and a small tracheostomy tube
inserted.
• After the tracheostomy has been in situ for the required length of time it is simply
removed. The hole through which it was inserted almost inevitably closes without any
intervention.
• Patients with long-term tracheostomies are unable to vocalize because no air is
passing through the vocal cords.
1◊The laryngeal nerves bear relationships to the thyroid arteries which are
of considerable practical importance in thyroidectomy. The external branch
of the superior laryngeal nerve lies immediately deep to the superior
thyroid artery and may be injured in ligating this vessel. The recurrent
laryngeal nerve, lying in the tracheo-oesophageal groove, is usually behind
the terminal branches of the inferior thyroid artery. Occasionally, however,
the nerve lies in front of these vessels or passes between them (Fig. 191).
Moreover, when a large thyroid is pulled forward during thyroidectomy, the
nerve becomes dragged forward with it and is therefore placed in further
jeopardy. To avoid nerve damage during ligation of the inferior thyroid
artery, this procedure should be carried out well laterally, just as the artery
emerges from behind the carotid sheath and before it takes up its intimate
and inconstant relationship to the nerve.
2◊◊Damage to the superior nerve causes some weakness of phonation due
to the loss of the tightening effect of the cricothyroid muscle on the cord.
3◊◊Complete division of a recurrent laryngeal nerve causes the cord on the
affected side to take up the neutral (or paramedian) position between
abduction and adduction. Usually the other cord is able to compensate in a
remarkable way and speech is not greatly affected; if both nerves are divided,
however, the voice is completely lost and breathing becomes difficult through the
only partially opened glottis.
4◊◊If the recurrent nerve is only bruised or partially damaged, the abductors
(posterior cricoarytenoids) are affected more than the adductors; this is
known as Semon’s law. The affected cord adopts the midline adducted position.
In bilateral incomplete paralysis, therefore, the cords come together,
stridor is intense and tracheotomy may become essential.
5◊◊The left recurrent laryngeal nerve, in its thoracic course, may become
involved in a bronchial or oesophageal carcinoma, or in a mass of enlarged
mediastinal nodes, or may become stretched over an aneurysm of the aortic
arch. The enlarged left atrium in advanced mitral stenosis may produce a
recurrent laryngeal palsy by pushing up the left pulmonary artery which
compresses the nerve against the aortic arch.
Seorang begal laki-laki tertembak peluru. Peluru
masuk di sela iga ke-4 kanan. Hasil pemeriksaan
radiograsi menunjukkan adanya udara di cavum
pleura.
Diagnosis?
Tatalaksana terkait anatomi?

Pengambilan udara/cairan di dalam cavum pleura.

Insersi chest drain:


• Midaxillary line: sela iga ke-5
• Midclavicular line: sela iga ke-2
• f air is introduced into the pleural cavity, a pneumothorax develops and the
lung collapses because of its own elastic recoil. The pleural space fills with air,
which may further compress the lung. Most patients with a collapsed lung are
unlikely to have respiratory impairment. Under certain conditions, air may
enter the pleural cavity at such a rate that it shifts and pushes the
mediastinum to the opposite side of the chest. This is called tension
pneumothorax and is potentially lethal, requiring urgent treatment by
insertion of an intercostal tube to remove the air. The commonest causes of
pneumothorax are rib fractures and positive pressure ventilation lung
damage.
• The pleural cavity may fill with fluid (a pleural effusion) and this can be
associated with many diseases (e.g. lung infection, cancer, abdominal sepsis).
It is important to aspirate fluid from these patients to relieve any respiratory
impairment and to carry out laboratory tests on the fluid to determine its
nature.
• Severe chest trauma can lead to development of hemopneumothorax. A tube
must be inserted to remove the blood and air that has entered the pleural
space and prevent respiratory impairment.
• This man needs treatment to drain either the air or fluid or both.
• The pleural space can be accessed by passing a needle between the ribs into the
pleural cavity. In a normal healthy adult, the pleural space is virtually nonexistent;
therefore, any attempt to introduce a needle into this space is unlikely to succeed and
the procedure may damage the underlying lung.
• Before any form of chest tube is inserted, the rib must be well anesthetized by
infiltration because its periosteum is extremely sensitive. The intercostal drain should
pass directly on top of the rib. Insertion adjacent to the lower part of the rib may
damage the artery, vein, and nerve, which lie within the neurovascular bundle.
• Appropriate sites for insertion of a chest drain are:
in the midaxillary line in the fifth intercostal interspace;
in the midclavicular line in the second intercostal interspace.
These positions are determined by palpating the sternal angle, which is the point of
articulation of rib II. Counting inferiorly will determine the rib number and simple
observation will determine the points of the midaxillary and the midclavicular line.
Insertion of any tube or needle below the level of rib V runs an appreciable risk of
crossing the pleural recesses and placing the needle or the drain into either the liver or
the spleen, depending upon which side the needle is inserted.
Pleura
• Pembungkus –paru-paru
• 2 lapis: pleura parietalis dan visceral
• Diantaranya terdapat ruang potensial, cavum
pleura.
• Recessus/ perluasan cavum pleura: recessus
costomediastinal dan costodiafragmatica. Recessus
terbentuk karena paru tidak penuh mengisi cavum
pleura.
Pleura

Batas:
• Superior: hingga di atas costae
1, mencapai area leher (3-4
cm), cupula
• Medial: mediastinum
• Inferior: diafragma
Lapisan pleura:
• Parietal
• Visceral
Pleura

Recessus
• Recessus costodiafragmatica
• Recessus costomediastinalis
Proyeksi pleura dan paru pada dinding dada
Proyeksi pleura dan paru pada dinding dada
Proyeksi pleura
dan paru pada
dinding dada
Auskultasi paru
Auskultasi paru
Aplikasi klinis

Thoracocentesis:
• Garis midaxillaris, sela
iga ke-5 (haemothorax)
• Garis midclavicular, sela
iga ke-2
• Sela iga ke-7
• Di bawah sela iga ke-7,
resiko mengenai
diafragma
• Fluid can be drained from the pleural cavity by inserting a wide-bore needle
through an intercostal space (usually the 7th posteriorly). The needle is passed
along the superior border of the lower rib, thus avoiding the intercostal nerves
and vessels (Fig. 8). Below the 7th intercostal space there is danger of
penetrating the diaphragm.
3◊◊For emergency chest drainage—for example traumatic haemothorax or
haemopneumothorax—the site of election is the 5th intercostal space in the
mid-axillary line. An incision is made through skin and fat and blunt dissection
carried out over the upper border of the 6th rib. The pleura is opened, a finger
inserted to clear any adhesions and ensure the safety of the adjacent
diaphragm before inserting a tube into the pleural space and connecting it to
an under-water drain.
4◊◊Since the parietal pleura is segmentally innervated by the intercostal
nerves, inflammation of the pleura results in pain referred to the cutaneous
distribution of these nerves (i.e. to the thoracic wall or, in the case of the
lower nerves, to the anterior abdominal wall, which may mimic an acute
abdominal emergency).
Three common pathologic processes may occur in the pleural cavity.
If air is introduced into the pleural cavity, a pneumothorax develops and the
lung collapses because of its own elastic recoil. The pleural space fills with air,
which may further compress the lung. Most patients with a collapsed lung are
unlikely to have respiratory impairment. Under certain conditions, air may
enter the pleural cavity at such a rate that it shifts and pushes the mediastinum
to the opposite side of the chest. This is called tension pneumothorax and is
potentially lethal, requiring urgent treatment by insertion of an intercostal tube
to remove the air. The commonest causes of pneumothorax are rib fractures
and positive pressure ventilation lung damage.
The pleural cavity may fill with fluid (a pleural effusion) and this can be
associated with many diseases (e.g. lung infection, cancer, abdominal sepsis). It
is important to aspirate fluid from these patients to relieve any respiratory
impairment and to carry out laboratory tests on the fluid to determine its
nature.
Severe chest trauma can lead to development of hemopneumothorax. A tube
must be inserted to remove the blood and air that has entered the pleural
space and prevent respiratory impairment.
This man needs treatment to drain either the air or fluid or both.
The pleural space can be accessed by passing a needle between the ribs into the
pleural cavity. In a normal healthy adult, the pleural space is virtually nonexistent;
therefore, any attempt to introduce a needle into this space is unlikely to succeed and
the procedure may damage the underlying lung.
Before any form of chest tube is inserted, the rib must be well anesthetized by
infiltration because its periosteum is extremely sensitive. The intercostal drain should
pass directly on top of the rib. Insertion adjacent to the lower part of the rib may
damage the artery, vein, and nerve, which lie within the neurovascular bundle.
Appropriate sites for insertion of a chest drain are:
in the midaxillary line in the fifth intercostal interspace;
in the midclavicular line in the second intercostal interspace.
These positions are determined by palpating the sternal angle, which is the point of
articulation of rib II. Counting inferiorly will determine the rib number and simple
observation will determine the points of the midaxillary and the midclavicular line.
Insertion of any tube or needle below the level of rib V runs an appreciable risk of
crossing the pleural recesses and placing the needle or the drain into either the liver
or the spleen, depending upon which side the needle is inserted.
Trachea, bronchus dan hubungannya dengan
paru
• Trachea membentang mulai C VI – T IV,.
• Trachea berbentuk seperti setengah cincin, bagian terbukanya
menghadap ke posterior
• Setelah T IV, trachea terbagi 2 menjadi bronchus principalis
dexter dan sinister
• Selanjutnya setiap bronchus bercabang-cabang menjadi
bronchus lobaris (sesuai dengan lobus paru), segmentorum
hingga berakhir sebagai alveolus
• Bronchus principalis kanan lebih besar dan sudut bifurkasi
lebih tumpul  benda asing lebih sering masuk
Bronchus
Paru-paru
Vaskularisasi
• A/v. pulmonalis mengikuti segmen paru, aa.
Segmentales
• Vena-vena dari pleura parietalis muara ke vena
sistemik
• Vena-vena daro pleuran visceralis muara ke v.
pulmonalis
• A.bronchiales
• A.bronchiales dextra a.intercostalis superior posterior; a.
bronchialis superior sinistra
• A.bronchialies sinistra: aorta thoracica
Paru-paru
Vaskularisasi
• a/v. pulmonalis
Persarafan paru

• Pleura visceralis: tidak sensitif terhadap nyeri 


innervasi otonom(motorik dan aferen viseral, tidk
memiliki komponen sensasi umum).
• Pleura parietalis: sensitif terhadap nyeri, terutama
pleura costalis  mendapat persarafan dari
n.intercotalis dan n.phrenicus.
Visceral eferen:
• N X: konstriksi
bronchiolus
• Simpatis:
dilatasi
bronchus
Aliran limfatik
Mekanisme
respirasi
Otot-otot respirasi
Mekanisme
respirasi
Inspirasi
• Diafragma
• M.intercostais externus
Inspirasi dalam
+ otot-otot:
• Sternocleidomastoideus
• Scaleni
• Pectorales
• Quadratus lumborum
Mekanisme
respirasi
Ekspirasi
• Diafragma
• M.intercostais internus
Inspirasi dalam
+ otot-otot abdominal
(m.obliquus abdominis
externus, internus dan
m. transversus
abdominis)
Referensi
• Anne M. Gilroy, et al. Atlas of Anatomy. Thieme. 2009
• Elaine n Marieb, Patricia Brady Wilhem & Jon Mallat. Human
Anatomy. 6th ed. Benjamin Cummings. 2012.
• Keith L. Moore, Arthur F. Dalley & Anne M. Agur. Clinically oriented
Anatomy. 7th ed. Lippincott Williams & Wilkins. 2015
• Richard L Drake, Wayne Vogl, Adam W.M. Mitchell. Gray’s Anatomy
for Students.3rd ed. Elsevier. 2015.