CHEST AND LUNGS

AXEL LANGUIDO ELISES, MD, FPSGS, FPALES, FPCS, PATOS

Learning Objectives
Objectives
 Describe the bones of the thorax
(sternum, ribs & cartilages, thoracic
vertebrae & joints)
 Distinguish between true, false & floating
ribs, and typical & atypical ribs
 Describe the structure & function of thoracic
vertebrae
 Describe & compare the articulations of the
thorax

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

Objectives
 Describe the origin, insertion & function
of chest wall muscles, and position of
the intercostal muscles, as well as of the
intercostal VAN
 Describe the blood and nerve supply of
the thoracic wall
 Describe the parietal & visceral pleura,
and pleural space

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

Objectives
 Describe & locate the apertures
 Describe the position of the lungs within
the thoracic cavity
 Identify the structures found at the root
of each lung
 Compare and contrast the gross
anatomy of the right & left lung

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

Objectives
 Describe the structure of the trachea &
bronchi
 Describe the components of the
bronchial tree, the lobes & the
bronchopulmonary segments
 Describe & explain the movements of
the chest wall

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

Course Outline
 Thoracic Cage  Thoracic vertebrae
 Sternum  Typical (2-8)
 Atypical (1, 10-12)
 Manubrium
 Body  Thoracic Muscles
 Xiphoid process  External intercostal
 Internal intercostal
 Ribs
 Innermost
 True (1-7)
intercostals
 False (8-12)
 Others
 Floating (11 & 12)
 Vasculature
 Atypical & Typical

 Articulations  Innervation
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
Course Outline
 Thoracic Cavity  Bronchial Tree
 Pleural  Primary bronchi (2)
 Parietal  Secondary bronchi
 Visceral
 Bronchioles
 Diaphragm
 Terminal
 Apertures bronchioles
 Trachea  Respiratory zone

 Lungs  Bronchopulmonary
 Lobes segments
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
Course Outline
 Respiratory
movements

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 Thorax = chest
 region between the neck & abdomen
 Sternum
 Manubrium
 trapezoidal
 widest, thickest

 Jugular/ Suprasternal notch

 Clavicular notches

 Synchondrosis of 1st rib

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 Manubriosternal joint/Sternal angle
(of Louis)
 articulates with cartilage of 2nd ribs
 level where aorta begins & ends

 level where the trachea bifurcates

 level of the inferior border of

superior mediastinum
 level between T4 & T5 vertebrae

 Body
 formed by 4 Sternebrae
(synchondroses)
 articulates with 2nd to 7th costal
cartilages Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAGE
 articulates with xiphoid, xiphisternal
joint, level of T9 vertebra
 Xiphoid process
 cartilaginous which gradually ossify
 level of T10 vertebra

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 Ribs
 Classification
 True (1-7)
 attached to sternum with their costal cartilages
(vertebrosternal)
 False (8-12)
 attached to the costal cartilage immediately above (7th) –
(vertebrochondral)
 forms the anterior costal arch or costal margin

 Floating (11 & 12)

 connected only to the vertebrae, no costal cartilage

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 Structure
 Typical
 3rd to 9th ribs; parts:
 Head
 articulates with corresponding vertebral bodies,
IV disks & supradjacent vertebral bodies
 Neck
 Tubercle
 articulates with transverse processes of
corresponding vertebrae
 Shaft/ Body
 thin, flat; turns anteriorly (angle)
 costal groove
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAGE
 Atypical
 1st Rib
 broadest, shortest
 one articulation – costovertebral joint
 scalene tubercle
 subclavian groove
 2nd Rib

 2 articulating facet, head (1st & 2nd vertebrae)

 2 x longer than the 1st rib
 tuberosity for serratus anterior

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 10th Rib
 1 articulating facet, head – to corresponding vertebra
 11th Rib

 1 articulating facet, head – to corresponding vertebra

 no neck, no tubercle
 12th Rib

 1 articulating facet, head – to corresponding vertebra

 no neck, no tubercle

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 Thoracic vertebrae
 Typical features (T2-T9):
 Bilateral costal demifacets on the vertebral bodies
 head of ribs (corresponding rib & subsequent rib
below)
 Costal facets on the transverse processes 
tubercles of ribs
 Articular processes extend vertically

 Superior articular facets: flat, directed upward,

backward & facing laterally
 Inferior articular facets: flat, directed downward,
forward & facing Property
medially
of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAGE
 -shaped bodies
 Long, inferiorly slanting spinous processes

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAGE
 Thoracic vertebrae
 Atypical thoracic vertebrae
 T1
 Long, horizontal spinous process =
Vertebra prominens
 Complete costal facet for the 1st rib

 Demifacet for the 2nd rib

 T10
 1 complete facet on each side
 No INFERIOR demifacet

 T11-12
 same with T10; No transverse costal facets
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
 THORACIC CAGE
 Articulations
Joint Type Articulation Ligaments
Saddle type, Synovial Clavicle  Manubrium,  Anterior & Posterior
Sternoclavicular joint 1st costal cartilage sternoclavicular
 Costoclavicular
1st : Primary 1st costal cartilage  • Anterior & Posteror
cartilaginous joint – Manubrium radiate sternocostal
Synchondrosis • Intra-articular
Sternocostal –
2nd 7th
costal cartilage
2nd – 7th : Plane,  Sternum
Synovial

Primary cartilaginous Costal cartilage  • cartilage & bone

Costochondral joint – Synchondrosis Sternal end of ribs bounded by
periosteum
Secondary cartilaginous Manubrium  Sternum
Manubriosternal joint – Symphysis
Primary cartilaginous Xiphoid  Sternum
Xiphisternal joint – Synchondrosis
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
 THORACIC CAGE
 Articulations
Joint Type Articulation Ligaments
Head of rib  superior  Radiate & Intra-
demifacet/ costal facet articular ligaments of
of corresponding head of ribs
vertebra, inferior  Lateral & Superior
demifacet of costotransverse
Costovertebral Plane, Synovial joint
supradjacent vertebra &
IV disk
Tubercle, rib 
corresponding
transverse process
Plane, Synovial joint Between 6th – 7th , 7th – • Interchondral
8th , 8th – 9th costal
cartilages
Interchondral
Fibrous Between 9th – 10th
costal cartilages
Secondary cartilaginous Vertebral body  Disk • Anterior & Posterior
Intervertebral joint – Symphysis  Vertebral body Longitudinal
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
 THORACIC CAGE
 Articulations
Joint Type Articulation Ligaments
Facet of the tubercle of  Articular capsule
the rib  adjacent  Posterior
transverse process of a costotransverse
thoracic vertebra  Lateral
costotransverse
 Superior
Costotransverse Plane, Synovial joint costotransverse
 Inferior
costotransverse
 Ligament of neck of
rib
 Ligament of tubercle
of rib

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

 THORACIC CAGE
 Thoracic wall muscles
Muscle Origin Insertion Nerve Supply Action

External Lower border, ribs Upper border, rib Intercostal nerve Elevate ribs
Intercostals below (inspiration)

Internal Depress ribs

Intercostals (costal part)

Innermost Elevate ribs

Intercostals (interchondral part)

Posterior surface, Inner surface, 2nd Depresses ribs

Transversus
lower sternum & – 6th costal
thoracic xiphoid cartilages
Inner surface near Upper border, 2-3 Elevate ribs
Subcostalis angle, lower ribs ribs below

Transverse Between tubercle Dorsal primary Elevate ribs

Levator
processes, T7 – & angle, subjacent rami, C8-T11
costarum T11 ribs
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
 THORACIC CAGE
 Thoracic wall muscles
Muscle Origin Insertion Nerve Supply Action

Serratus Nuchal ligament, Upper borders, 2nd 2nd – 5th intercostal Elevate ribs
Spinous – 4th ribs nerves (Proprioception)
Posterior processes (C7 –
Superior T3)
Serratus Spinous Lower border Anterior rami to T9 Depress ribs
Posterior processes (T11 – (near the angle), – T12 spinal (Proprioception)
Inferior L2) 8th – 12th ribs nerves

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

 THORACIC CAGE
 Thoracic wall muscles
Muscle Origin Insertion Nerve Supply Action

Accessory Respiratory Muscles

Pectoralis
Major

?
Pectoralis
Minor
Serratus
Anterior

Scalene

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

 THORACIC CAGE
 Thoracic wall blood supply
Artery Origin Course Distribution
Superior intercostal
Posterior artery (1st & 2nd ICS),
Intercostals
Thoracic aorta Between internal & • Intercostal muscles
Internal thoracic artery innermost intercostal • Overlying skin
(1st – 6th ICS), muscles • Parietal pleura
Anterior
Intercostals Musculophrenic arteries
(7th – 9th ICS)
Subclavian artery Inferior & lateral to Thru Anterior Intercostal
sternum between costal arteries (1st – 6th ICS),
cartilages & internal Musculophrenic artery
thoracic muscle  (lateral)
Internal Thoracic Superior epigastric
artery & Musculophrenic
artery

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

 THORACIC CAGE
 Thoracic wall blood supply
Artery Origin Course Distribution
Thoracic aorta Lower border, 12th rib To muscles of
Subcostal anterolateral abdominal
wall
Superior Axillary artery (1st Medial upper border of To 1st & 2nd ICS,
division) the pectoralis minor, Serratus anterior;
Thoracic passes between the Anastomose with
(Supreme pectoralis major & minor Internal Thoracic artery
Thoracic) to the side of the chest & Intercostal arteries
Axillary artery (2nd part) Along the lower border Supplies the Serratus
of pectoralis minor anterior muscle & the
Pectoralis major, axilla
Lateral Thoracic & Subscapularis.
Anastomoses with
(External Internal thoracic artery,
Mammary) Subscapular, Intercostal
arteries, and pectoral
branch of
Property of Axel L. Elises, MD, FPSGS,thoracoacromial
FPALES, FPCS, PATOS
artery.
THORACIC CAGE
 Intercostal nerves
 anterior primary rami of the 1st 11 thoracic
spinal nerves
 anterior primary ramus of the 12th thoracic
spinal nerve – subcostal nerve
 between internal & innermost intercostal
muscles
 along the costal groove (sVANi)
 gives off anterior & lateral cutaneous
branches and muscular branches
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAVITY
 Pleura
 Parietal pleura
 parts:
 Cervical (Cupula)
 Suprapleural membrane (Sibson’s fascia)
 Costal

 Diaphragmatic

 Mediastinal

 innervated by intercostal nerves (costal,

diaphragmatic) & phrenic nerve ( diaphragmatic,
mediastinal)
 sensitive to pain
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAVITY
 blood supply:
 Internal Thoracic artery
 Superior Phrenic artery

 Posterior Intercostal arteries

 Superior intercostal arteries

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAVITY
 Visceral pleura
 invests the lung
 blood supply:
 bronchial arteries
 insensitive to pain, sensitive to stretch

 Pleural Cavity
 closed sac with no communication between right &
left
 contains lubricant  facilitates movement of lungs

 Costodiaphragmatic recesses

 Costomediastinal recesses
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAVITY
 Diaphragm
 Origin:
 Sternal : Xiphoid process
 Costal : Lower 6 costal cartilages
 Lumbar : Medial & lateral lumbocostal arches
 Right crus : L1 – L3 vertebrae
 Left crus : L1 – L2 vertebrae
 Insertion:Central tendon
 Innervation:
 Somatic motor fibers: Phrenic nerve
 Sensory: Phrenic nerve (central), Intercostal nerves
(peripheral)
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
THORACIC CAVITY
 Blood supply:
 Musculophrenic artery
 Pericardiophrenic artery
 Superior phrenic artery
 Inferior phrenic artery

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAVITY
 Apertures
 Superior Thoracic Aperture
 Borders:
 Anterior : Manubrium, superior border
 Lateral : 1st ribs & their costal cartilages
 Posterior : T1 vertebra, body

 6.5 cm AP, 11 cm transverse diameter

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAVITY
 Posterior Thoracic Aperture
 Borders:
 Anterior : Xiphisternal joint
 Lateral :
 Costal cartilages of 7th – 10th ribs = costal margins
(anterior)
 11th – 12th ribs (posterior)
 Posterior : T12 vertebra,body

 Openings:
 Vena Caval Hiatus
 in the central tendon, level of T8
 transmits IVC & Right Phrenic nerve

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

THORACIC CAVITY
 Esophageal Hiatus
 in the muscular part of diaphragm (right crus), level
of T10
 transmits Esophagus and Vagus nerves, anterior &
posterior trunks
 Aortic Hiatus

 behind & between the 2 crura, level of T12

 transmits Aorta, Thoracic duct, Azygos vein and
Greater splanchnic nerve

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

TRACHEA
 10 – 16 centimeters long x 2.5 centimeters
in diameter
 commences at the lower border of the larynx,
level of C6 vertebra
 courses anterior to the esophagus, inclined to
the right
 terminates at the level of T4 - T5 vertebrae,
carina of the trachea:
 bifurcation into the right & left primary bronchi
 opposite the sternal angle, positioned up to 2
vertebrae lower or higher, depending on breathing
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
TRACHEA
 fibrocartilaginous tube:
 incomplete tracheal rings
 trachealis muscle
 completes the ring; involuntary muscle
 constricts the trachea, allows air to be expelled
with more force (coughing)
 innervated by CNX, upper thoracic spinal nerves

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

LUNGS
 has an apex & a base
 lobes – 3 on the right, 2 on the left,
created by one or two fissures
 3 surfaces (Costal, Diaphragmatic,
Mediastinal)
 3 borders (anterior, posterior, inferior)

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

LUNGS
 Right lung:
 superior to inferior:
 Eparterial bronchus
 right superior lobar bronchus
 Pulmonary artery
 Hyparterial bronchus
 right middle & inferior
lobar bronchi
 Pulmonary veins

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

LUNGS
 Left lung:
 superior to inferior:
 Pulmonary artery
 Bronchus

 Pulmonary veins

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

 BRONCHIAL TREE
 Primary bronchi
 Right: wider, shorter, runs more vertically as it
passes directly to the hilum of the lung
 Left: passes inferolaterallyPARASYMPATHETIC
SYMPATHETIC

 inferior to the arch ofVasodilation

Vasoconstriction the aorta
Bronchodilation Bronchoconstriction
 anterior to the esophagus & thoracic aorta
 Blood supply: Bronchial arteries (1R,2L)
 Venous drainage: Bronchial veins, Rt. –
Azygous vein; Lt. – Hemiazygous vein
 Nerve supply: Pulmonary plexus – CN X &
sympathetics Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
BRONCHIAL TREE
 Secondary (lobar) bronchi
 Right (3), Left (2)
 supplies each lobes

 Tertiary (Segmental) Bronchi/

Bronchioles
 supplies the bronchopulmonary segments

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

LUNGS
 Right lobes:
 Superior
 Apical
 Posterior
 Anterior
 Middle
 Lateral
 Medial
 Inferior
 Superior
 Posterior Basal
 Anterior Basal
 Lateral Basal
 Medial Basal
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
LUNGS
 Left lobes:
 Superior
 Apical *
 Posterior *
 Anterior
 Superior Lingual
 Inferior Lingual
 Inferior
 Superior
 Posterior Basal
 Anterior Basal **
 Lateral Basal **
 Medial Basal

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

LUNGS

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

BRONCHIAL TREE
 Bronchopulmonary segments (18-20)
 Largest subdivisions of a lobe
 surgically resectable
 Pyramidal-shape, separated from adjacent
segments by connective tissue septa
 Supplied independently by:
 segmental bronchus
 tertiary branch of the pulmonary artery

 Drained
by intersegmental parts of the
pulmonary veins
Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
RESPIRATORY MOVEMENT
 Vertical dimension (height)
 increases during inspiration
 contraction diaphragm  descent of diaphragm 
compresses abdominal viscera
 decreases or returns to neutral position in
expiration
 elastic recoil of the lungs  decreases
atmospheric pressure within the pleural space
 diaphragm ascends

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

RESPIRATORY MOVEMENT

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

RESPIRATORY MOVEMENT
 AP dimension
 intercostalmuscles contract upper 2nd – 6th
ribs at the costovertebral joints around an axis
passing through the necks of the ribs 
anterior ends of the ribs to rise, anterior–
posterior movement of the sternum (pump-
handle movement)

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS

RESPIRATORY MOVEMENT
 Transverse dimension
 Intercostal muscles contract lifts the middle/
lateral part of the lower ribs (bucket-handle
movement)

 During inspiration the thoracic cage moves

anteriorly, superiorly, & laterally
 During expiration the intra-thoracic
pressure increases, intraabdominal
pressure decreases Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS
RESPIRATORY MOVEMENT

Property of Axel L. Elises, MD, FPSGS, FPALES, FPCS, PATOS