Respiratory Applied Anatomy

• Surface anatomy of the chest

  • Clavicles
  • Jugular notch
  • Manubrium of sternum
  • Manubriosternal joint (sternal angle)
  • Rib 2, 3, 4, 5
  • Intercostal spaces
  • Costal margin
  • Lateral sternal edge (R & L)
  • Mid-clavicular line
  • Anterior axillary line
• Case courtesy of Henry Knipe, Radiopaedia.org, rID: 160360
• Diagnosis


  Potential pneumothorax with fractured rib
• Concern


  Potential pneumothorax with fractured rib
• Next step


  CT scan to investigate surrounding structures
• Work of breathing


  Ribcage, intercostal muscles, diaphragm
• What to avoid


  Lying them flat
• 24-year-old cyclist clipped by the car, self-presented to ED, initial observations normal, very painful chest wall, good air entry both sides, clearly guarding injured side
• Fracture of 7th rib on left side, posterior (more horizontal)
• Thoracic cage


  • Ventilation – Allows muscles to change the thoracic volume and bring about respiration
  • Protection – Strong cage to give protection to some vital organs
• Thoracic cage composed of: 12 thoracic vertebrae, 12 pairs of ribs (i.e. 24 ribs), Cartilage structures, Sternum – 3 parts
• Rib fracture, 7th rib, posterior
• Potential issues


  Pneumothorax? Pain, compromised ventilation
• Respiratory Tract


  Medical knowledge, skills and behaviours for patient care 1 (UM4001)
• Where to insert needle

  Above the rib – to ensure that you wont damage the neurovascular bundle which you might if you insert below the rib
• Atypical ribs 1,2, 10-12

  • Ribs 1-7 attach independently to the sternum
  • Ribs 8 – 10 attach to the costal cartilages superior to them
  • Ribs 11 and 12-- 'floating ribs'
• Atypical ribs 1,2, 10-12

  • Costotransverse joint – Between the tubercle of the rib, and the transverse costal facet of the corresponding vertebra
  • Costovertebral joint – Between the head of the rib, superior costal facet of the corresponding vertebra, and the inferior costal facet of the vertebra above
• How to treat rib fracture

  Analgesia: PCA/ Nerve blocks, Anaesthesia + PPV, ORIF
• Why treatment is important

  Ineffective ventilation, pulmonary contusion, hypoventilation with atelectasis
• Physician Associate Programmes
• Flail chest


  • Life threatening condition, 3 or more ribs broken at least in 2 places, Likely impending respiratory failure, Intubation and surgery are likely
• Fell from the tree (5 metres), main complaint pain in the left shoulder and chest, stable observations, XRay already performed
• Superior aperture/ thoracic inlet

  Boundaries: Manubrium, 1st ribs/ CC, T1, Contents: All vital structures of chest, head and upper limb
• Concern


  Think of Energy!!! Need further investigation, Subclavian artery injury
• 55 year old car driver, got rearended at 50 mph, admits not wearing seatbelt, tender anterior chest (where hit the wheel)
• Concern


  Mediastinum, Cardiac contusion, Risk of arrythmias
• Learning objectives


  • At the end of this session and on completion of the recommended reading, you will be able to:

  Describe the structure and function of the upper and lower airways

  Link clinical significance to each anatomical structure, including nasal trauma, obstruction, emergency airways, bronchodilator medications and mediastinal lymphadenopathy

  Describe the surface anatomy of the lungs ready to apply to clinical examination
• Nose


  Functions:

  Adjust temperature and humidity of inspired air (through a rich blood supply)

  Trap and remove particulates (hairs & mucous cells)

  Olfaction (Cranial nerve I)
• Nose


  • Cartilage provides support

  Hairs and glands to filter air

  Mucous membranes and conche increase surface area and moisturises air

  Highly vascular

  Equally rich nerve supply & specialised olfactory nerves
• Consider clinical consequences of anatomy
• Nasal Vasculature


  Epistaxis may be categorised as anterior or posterior depending on the origin of bleeding within the nasal cavity. Identifying the site of the bleed is crucial for management, and this skill depends on an understanding of the vascular supply of the nose.

  Dual arterial supply from both the internal and external carotid arteries.

  Most bleeds originate anteriorly in the nasal cavity in Little's area within Kiesselbach's plexus. This area is particularly vulnerable to dryness and trauma.
• Nose

  • Nasal gastric tube – used for feeding

  Nasal swab
• Nose


  • Breathing

  Bleeding

  Base of skull

  "Baby blues" (eyes)

  Beauty
• Pharynx


  AKA throat

  Fibromuscular funnel shaped tube

  Extends from posterior of nasal cavity to oesophagus

  Divided into nasopharynx, oropharynx and laryngopharynx

  Can visualise the oropharynx easily on examination
• Pharynx


  • FB

  Vomit

  Tongue
• Pharynx


  • Allergy

  Infection/ Inflammation

  Burn
• Pharynx


  • Lymph nodes

  Cancer

  Aneurysm

  Trauma
• Larynx


  AKA voice box

  A hollow musculo-ligamentous tube that has a cartilaginous framework

  Suspended form the hyoid bone

  Connects the pharynx to the trachea

  Function:

  Valve to close lower respiratory tract off from pharynx (so you don't choke)

  Instrument to produce sound
• Trachea & bronchial tree

  Trachea

  Primary bronchi (to lungs)

  Secondary bronchi (lobes)

  Tertiary bronchi (segmental)

  Terminal bronchi

  Bronchioles (no cartilage)

  Respiratory bronchiole

  Alveoli

  Trachea divides at carina

  Bronchopulmonary segment is a functionally independent region

  Bronchioles regulate airflow through bronchoconstriction and bronchodilation
• Trachea & bronchial tree


  • Davidson's Principles and Practice of Medicine. Reid, PT; Innes, JA. Published January 1, 2018. Pages 545-628. © 2018