Anatomy of the Trachea,

bronchi, lungs and pleura.

Presented by; Amira ahmed GSR1
Mediated by ; Dr adnan MD, general surgeon, ass prof of haramaya
university.
 • Trachea

 Points to cover
 anatomy and anatomical borders
 cervical and thoracic trachea and their relations
 blood supply
 Innervation
 lymphatic drainage
Anatomical borders

• Starts at larynx c6 and cricoid cartilage

• Then descends through the neck and thorax to its bifurcation at the level of T4/T5

• 10cm long, 2cm in diameter

• Covered by pretracheal fascia

• 15-20 incomplete cartilaginous rings which are completed in the posteriorly by

fibroelastic tissue and smooth muscle.

• It situated partly in the neck and partly in the mediastinum

• The trachea lies in the midline in its cervical course but is deviated slightly to the
right in its thoracic course.
 • Posterior is the esophagus
• Reccurent laryngeal nerve lying in the groof between
them
• Anterior there is infrahyoid muscles and cervical
Relations fascia, isthmus of the thyroid and left brachiocephalic
vein
• Laterally are lateral lobes of the thyroid gland ,
inferior thyroid artery and the carotid sheath.
Mobility

• Its upper end moves with larynx and the lower end moves with respiration.
Tracheal Patency

• The posterior ends of the cartilaginous rings are,held together by smooth

muscle called trachealis, which flattens the posterior wall of the trachea,
The soft posterior wall of the trachea allows for the expansion of the
esophagus during swallowing.
Clinical insight ...
• Importance of Carina
• If the tracheobronchial lymph nodes in the angle between the principal
bronchi enlarge (due to spread from bronchogenic cancer) the carina
becomes distorted and flattened. Therefore, morphological changes in the
carina are looked for during bronchoscopy
• iii. The left brachiocephalic vein may cross in front of the trachea in the
suprasternal notch in children. Similarly, the brachiocephalic artery may be
related to the trachea anteriorly just above the manubrium.
Anterior relations of cervical part of trachea
Posterior and lateral relations of cervical trachea

• Posteriorly, the trachea lies on the esophagus with recurrent laryngeal nerve
in the groove between trachea and esophagus.

• The trachea is related laterally to the lobes of the thyroid gland, inferior
thyroid arteries and common carotid artery in the carotid sheath.
Anterior relation of
thoracic part of
trachea
• i. The arch of aorta and its two branches,
brachiocephalic and left common carotid
arteries are in close relation
• ii. The left brachiocephalic vein crosses the
trachea from left to right and receives the
inferior thyroid veins, which descend in front
of the trachea.
• iii. Remains of thymus are in contact with
anterior surface.
• iv. At the tracheal bifurcation, the deep
cardiac plexus and tracheobronchial lymph
nodes are seen.
Posterior, left and right lateral relation

• Posterior; esophagus
• Left lateral; The trachea is related to the arch of aorta, left common carotid
artery and left subclavian artery. It is also related to the left recurrent
laryngeal nerve.
• Right lateral; Right Lateral Relations The trachea is in contact with the
mediastinal surface of right lung and pleura. Its vascular relations on the
right side are venous (right brachiocephalic vein, SVC and azygos arch). It
is also related to the right vagus nerve.
iii. The
tracheal veins drain into the
inferior thyroid venous plexus.
Blood supply

• Thoracic part of the trachea is supplied by bronchial arteries

• Cervical part is mainly supplied by inferior thyroid arteries
 • The nerve supply to the mucosa, tracheal glands
and trachealis muscle is from the vagus nerves,
recurrent laryngeal nerves and the sympathetic
Nerve supply trunks.
 Def; making an opening into the trachea

In purposes of assisting respiration

Or rerouting from an upper obstruction

Procedure ;

Tracheostomy separating the strap muscles and excising small 6-8 mm diameter
portion of the third / fourth tracheal ring below the thyroid isthmus.

Tracheostomy tube is then inserted into the trachea and retain by neck
straps

Cricothyrodotomy for emergencies; above cricoid cartilage

Tracheostomy ; below thyroid isthmus

 Types of pleura

Subdivisions of parietal pleura

Lines of pleural Reflections

Pleura
Nerve supply of pleura

Arterial supply of pleura

Functional importance of pleural cavity

THE PLEURA AND PLEURAL CAVITIES

• The pleura is a smooth shining serous membrane that covers the lungs.
• Divisble into two parts visceral and parietal and which has a potential space
between them.
• Visceral Pleura
i. The visceral pleura is inseparable from the lung.
ii. It dips into the fissures of the lungs.
iii. It shares the blood supply and nerve supply (autonomic
nerves) with that of the lung.
iv. It is insensitive to pain.
v. It develops from splanchnopleuric mesoderm.
Parietal pleura

• i. The parietal pleura is more extensive than the visceral pleura.

• ii. It lines the walls of thoracic cavity internally and is supported on its
external surface by a thick layer of endothoracic fascia.
• iii. It develops from somatopleuric mesoderm, hence is supplied by somatic
nerves.
• iv. It is pain sensitive.
Pleural reflections
and recesses.
Subdivisions of the
parietal pleura
Clinical insight

• i. The costodiaphragmatic recess (being the most dependent part of the

pleural cavity) shows widening in the radiograph, when a small quantity of
fluid accumulates in it. This may be the first indication of fluid in the
pleural cavity. Therefore, these recesses are examined routinely in the
radiographs of the chest.
• ii. In posterior approach to the kidney while removing a section of the
twelfth rib, care should be taken not to injure the inferior margin of pleura
in relation to the twelfth rib.
Nerve Supply of Pleura
• i. The visceral pleura receives innervation from autonomic nerves, hence it is
pain insensitive.
• ii. The parietal pleura is supplied by somatic nerves, hence it is sensitive to
painful stimuli. The pain is referred to the thoracic and abdominal walls or to the
neck and shoulder. The costal pleura receives twigs from intercostal nerves.
• iii. The peripheral part of diaphragmatic pleura receives branches from the
intercostal nerves whereas its central part from the phrenic nerves. The
mediastinal pleura is supplied by the phrenic nerve.
Arterial Supply of Pleura

• The visceral pleura is supplied by the bronchial arteries.

• the parietal pleura by the intercostal and internal mammary arteries.
Anatomy of the lungs

to be covered ;
External features of the right and left lungs
Surface markings of of lung
Relations of apex
Bronchial tree
Intra pulmonary airways
Bronchopulmonary segments
Blood supply of lungs
Lymphatic drainage
Nerve supply
External Features of Right and Left Lungs.
Right lung Left lung
Weight 600g 550g
Shape Broad and short Longer and narrower
Lobes 3 lobes 2 lobes
fissures 2 1
margins Sharp and straight anteriorly Sharp but not straight as it presents a
cardiac notch and a projecting lingula
below It.
Relations of the structrues at the hilum • Structures from above downwards
in the right lung are; eparterial
bronchus, pulmonary artery,
hyparterial bronchus and inferior
pulmonary vein.

• left lung, pulmonary artery,

principal bronchus and inferior
pulmonary vein.
Surface Marking of Lung
 • Anterior margin; coincides with costomedial line of
plueral reflection
The anterior margin of left lung coincides with the
costomeidalstinal line of pleural reflection up to the level of
fourth costal cartilage below this level it deviates from the
midline for a distance of 3.5cms. b/w the fourth and sixth
costal cartilages

Margins of the lung • Inferior margin; line starting sixth costal cartilage on
the left side and midpoint of the xiphisternum on the
right side.
Further tracing it cuts the sixth rib in the mid clavicular line,
eighth rib in the mid axillary line and tenth rib in the
scapular line .
• Posterior margin; lung extends vertically upwards from
the transverse process of the tenth thoracic vertebra to a
point lateral to the spine of the seventh cervical vertebra.
Relations of Apex.
Relations of the apex.
• Posteriorly, it is related to the sympathetic chain, highest intercostal vein,
superior intercostal artery and ascending branch of the ventral ramus of the first
thoracic nerve (from medial to lateral side). These structures are the anterior
relations of the neck of the first rib.
• Medial relations are different on the two sides. On the right side, from anterior
to posterior, the structures are, right brachiocephalic vein, right phrenic nerve,
brachiocephalic artery, right vagus and trachea. On the left side the order of
structures is, left brachiocephalic vein, left subclavian artery, left recurrent
laryngeal nerve, esophagus and thoracic duct
 • 1.The malignancy of the apex of the lung may
present as symptoms and signs produced due to
spread of cancer to neighboring structures. i.
Spread of cancer in subclavian or
brachiocephalic vein produces venous
Clinical insight engorgement and edema in the arm or neck and
face. ii. Pressure on the subclavian artery
results in diminished pulse in the arm (brachial
or radial, etc) on the affected side. iii.
Infiltration in the phrenic nerve results in
paralysis of hemidiaphragm
 • When the structures in posterior relation of
lung apex are involved due to cancer of lung
apex, it produces symptoms and signs, which
are collectively called pancoast syndrome.
• i. Pain in ulnar distribution and wasting of
Pancoast Syndrome small muscles of hand (due to injury to ventral
ramus of T1 or lower trunk of brachial plexus)
• ii. Horner’s syndrome (due to injury to
sympathetic chain)
• iii. Erosion of first or first and second ribs.
Medial Surface of right lung
Medial surface of left lung
Root of Lung

• The root of lung connects the mediastinum to the lung. All the structures,
which enter and leave the hilum of the lung, are enclosed in a tubular sheath
of mediastinal pleura. This tubular sheath with its enclosed contents is
called the root of the lung.
Root of lung

• Vertebral Level; The lung root lies opposite T5 to T7 vertebrae.

• Contents;
i. Single bronchus (principal bronchus on the left side) and two bronchi (eparterial and
hyparterial) on the right side
ii. Pulmonary veins
iii. Pulmonary artery
iv. Bronchial vessels
v. Lymph vessels and hilar or bronchopulmonary lymph nodes
vi. Pulmonary nerve plexuses.
Structures forming lung roots (encircled by green
rings)
Pulmonary ligament

• It is a double fold of mediastinal pleura below the level of pulmonary

hilum.
• There is a potential space between the two layers of the pulmonary
ligament, which provides a dead space for expansion of inferior pulmonary
veins during increased venous return and for the descent of lung root during
inspiration.
Bronchial tree
Right main bronchus Left main bronchus
length 2.5cm 5cm
lobes 3 2
segments 10 8
relations Inferior to azygos vein, superior to Inferior to aortic arch and crosses the
right pulmonary veings , anterior to esophagus anteriorly.
esophagus, posterior to right Anterior and inferior to left pulmonary
pulmonary artery veins.
Bronchopulmonary Segments
• Characteristics
Pyramidal in shape
Each segment is coveted with loose connective tissue
Each segment contains; pulmonary artery and of bronchial artery , tributaries of pulmonary veins
supported by connective tissue.
Each segment can be precisely located radiologically
Segmental resection is practiced in diseased segment .
During surgery the segmental bronchus of the diseased segment is located by dissection and it is
clamped along with the blood vessels. This enables to delineate the segment, as the surface of that
segment will darken due to loss of blood supply and air.
Intrapulmonary Airways

• conducting airways (from lobar bronchi to terminal bronchioles)

• respiratory areas (respiratory bronchioles, alveolar ducts, alveolar sacs and
alveoli.
• Air passages less than one mm in diameter are termed bronchioles.
Blood supply of the lungs

• Bronchial arteries
Single right bronchial artery takes origin from either the left bronchial artery
or the third right posterior intercostal artery or the descending
On the left side there are two bronchial arteries, upper and lower. Both are the
direct branches of descending thoracic aorta at the level of tracheal
bifurcation
Bronchial veins

• i. The right bronchial vein opens into the azygos vein.

• ii. The left bronchial vein opens into either the left superior intercostal vein
or the accessory hemiazygos vein.
Lymphatic drainage
• Lung cancer spreads by lymphatic path
• Superficial and deep lymphatic plexuses drain the lung
• Superficial plexus is sub-pleural
• Deep plexus is along the bronchi and blood vessels
• The two sets communicate at the hilum and drain into bronchopulmonary lymph nodes/ hilar lymph nodes.
They are black in color due to the carbon particles drained into them.
The efferent lymph vessels from hilar nodes drain into tracheobronchial and paratracheal nodes
Tracheo bronchial nodes communicate with the nodes in the base of the neck
They enlarge in pulmonary TB situations
Enlarged nodes may sometimes obstruct a lobar bronchus causing collapse of the entire lobe.
Nerve supply
• The lungs receive both sympathetic and parasympathetic nerves from the pulmonary plexuses.
i. The afferent fibers from the lung originate in endings sensitive to stretch, which are involved in
reflex control of respiration and coughing.
ii. The parasympathetic fibers are cholinergic. The parasympathetic stimulation causes
bronchoconstriction and increased secretion of the bronchial glands. The attack of bronchial asthma
is produced due to spasm of smooth muscles in the wall of bronchioles. This may be precipitated by
excessive vagal stimulation (due to exposure to pollen dust, cold air, ordinary dust, smoke, etc.).
iii. The sympathetic fibers are adrenergic. The sympathetic stimulation causes bronchodilatation,
vasoconstriction and decreased secretion.
iv. To counteract the spasm of the muscles in an attack of asthma, either sympathomimetic or
anticholinergic drugs are given. Sympathomimetic drugs like adrenaline mimic the action of
sympathetic stimulation (bronchodilatation). Anticholinergic drugs like atropine nullify the
bronchoconstriction action of cholinergic fibers, which results in dilatation of bronchi.
• Thank you