Respiratory system II.
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Transcript of Respiratory system II.
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Respiratory systemRespiratory systemII.II.
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Anatomical divisionAnatomical division
• upper respiratory tract– nasal cavity– paranasal cavities– nasopharynx
• lower respiratory tract– larynx– trachea– tracheobronchial tree– respiratory compartment
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Anatomical Anatomical divisiondivision
• upper respiratory tract– nasal cavity– paranasal cavities– nasopharynx
• lower respiratory tract– larynx– trachea– tracheobronchial tree– respiratory compartment
Surgical divisionSurgical division
• upper respiratory tract– nasal cavity– paranasal cavities– nasopharynx– larynx
• lower respiratory tractborder: apertura thoracis sup.
– trachea– tracheobronchial tree– respiratory compartment
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General structure of respiratory system wallGeneral structure of respiratory system wall • tunica mucosa (mucosa)
– epithelium- ciliated pseudostratified columnar (respiratory epithelium)
- non-keratinized stratified squamous
- lamina basalis– lamina propria
• glands (seromucinous tuboalveolar), lymph nodes (noduli lymphoidei)
• tunica fibromusculocartilaginea– collagenous and elastic tissue (and its ligaments – larynx, trachea)– smooth muscles (trachea, bronchi, bronchioli)– skeletal muscles (larynx)
• tunica serosa or tunica adventitia– tunica serosa (pleura) has three layers:
• mesothelium– lamina basalis
• lamina propria• tela subserosa
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TracheaTrachea
• pars cervicalis (C6- C7)
• pars thoracica (T1-T4)
newborn at the level of C4, child C5
• bifurcatio tracheae (T4)
= 1st branching of tracheobronchial tree
• carina tracheae
• calibers: length 10-11 cm, width 25 mm
• syntopy: ventrally thyroid gland, dorsally oesophagus
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TRACHEA
Pars cervicalis
Pars thoracica
Cartilagines tracheales
M. trachealis
Ligg. anularia / trachealia
Paries membranaceus
Bifurcatio tracheae
Carina tracheae
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Endoscopy view of tracheaEndoscopy view of trachea
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Trachea – supplyTrachea – supply• Arteries:
– a. thyroidea inf. → rr. tracheales– aorta thoracica → rr. bronchiales– (a. thyroidea ima – 2 %)– newborns and children – branches from thymus arteries
• Veins:– drain into oesophageal veins, into plexus thyroideus
impar and into v. brachiocephalica sin. • Lymph:
– nodi tracheobronchiales, nodi tracheales → truncus bronchomediastinalis dx.+ sin.
• Nerves:– n. vagus → n. laryngeus recurrens– truncus sympathicus
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Coniotomy (coniopuncture)Coniotomy (coniopuncture)
emergency procedure in outdoor (rare)
transversal section between cartilago thyroidea et cricoidea through lig. cricothyroideum medianum
Approach passes through following layers:• skin + subcutaneous tissue• lamina superficialis fasciae cervicalis• lamina pretrachealis fasciae cervicalis• lig. cricothyroideum medianum + mucosa
!Cave! – interconnection of rr. cricothyroidei a. laryngeae superioris below cartilago thyroidea
– lobus pyramidalis glandulae thyroideae (40%)
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TracheotomyTracheotomysagittal section for canylation through several tracheal
cartilages (done in hospital)• tracheostomia superior
– above isthmus glandulae thyroideae (in the extent of cartilago trachealis 2-4)
• tracheostomia inferior – below isthmus, above incisura jugularis
Approach passes through following layers:• skin + subcutaneous tissue• lamina superficialis fasciae cervicalis• venous arcus venosus jugularis (only in lower tracheotomy)• lamina pretrachealis fasciae cervicalis
+ cutting through midline fibrous connection of both mm. sternohyoidei(only in lower tracheotomy)
• venous plexus thyroideus impar (only in lower tracheotomy)• cartilagines tracheales + ligg. anularia + mucosa
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• coniotomy
• upper tracheotomy
• lower tracheotomy
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Tracheotomy – risks
bleeding from:
• plexus thyroideus impar
• a. thyroidea ima (2%)
• arcus venosus jugularis
• lobus pyramidalis glandulae thyroideae (40%)
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Trachea – wall structureTrachea – wall structure
• epithelium of respiratory tract
• glandulae tracheales – seromucous glands
• cartilagines tracheales (15-20)– C-shaped rings
• ligg. anularia / trachealia
• paries membranaceus – dorsal wall
• m. trachealis – smooth (horizontal as well as longitudinal fibers)
• adventicia on the surface
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Tracheobronchial tree (Tracheobronchial tree (Arbor bronchialisArbor bronchialis) )
23 divisions – dichotomic branching• primary bronchi (bronchus pricipalis dx.+ sin.)
– right: shorter, wider, straighter foreign body enters in 75% into the right one
• secondary bronchi (bronchi lobares)– 2 left and 3 right
• tertiary bronchi (bronchi segmentales)– 8 on the left and 10 on the right
• left: 1+2 connected, 7+8 connected in 90%• exception: 6th bronchus segmentalis of both sides
branches in trichotomic way!
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Tracheobronchial tree (Tracheobronchial tree (Arbor bronchialisArbor bronchialis))
• bronchi 4th order (bronchus subsegmentalis): b = ventral, a = dorsal• bronchi 5th order: ii = ventral, i = dorzal• bronchi 6th order: β = ventral, α = dorzal
• terminal bronchioli (bronchiolus terminalis) = 14th-16th order (originate by 14th division) 1 bronchiolus terminalis = 1 secondary pulmonary
lobulus (visible on the lung surface)
alveolar tree (originate by 17th branching)
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Bronchi (Bronchi (BronchiBronchi))tunica mucosa:• epithelium of respiratory tract
pseudostratified columnar with cilia• seromucous glands
tunica fibromusculocartilaginea:• cartilages have irregular shape (more peripheraly
disappear)• smooth muscle – spiral (more peripheraly
increases)• nodes of lymphoid tissue – at the branching
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Bronchioli (Bronchioli)
• caliber < 1 mm
• epithelium changes into simple cuboidal
• exocrinocyti bronchiolares (Clara cells)– produce constituents of surfactant, lysosomal
activity, mitotic activity
• no cartilage, glands and lymph nodes
• increase of elastic fibers
• 1 bronchiolus terminalis = 1 secondary pulmonary lobule
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Lungs (Lungs (PulmoPulmo))
description: basis, apex• facies costalis (+ pars vertebralis)• facies mediastinalis (+ impressio cardiaca)• facies diaphragmatica• (facies interlobaris)• margo anterior (incisura cardiaca p.sin.)• margo inferior• hilum pulmonis, radix pulmonis• fissura obliqua, fissura horizontalis p. dx.• impressions
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RIGHT LUNG LEFT LUNG
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Lungs – division
• hilum (clinically hilus)– structures: left „ABV“ - right „BAV“
• right lung – 3 lobes (sup., middle, inf.)
• left lung – 2 lobes (sup., inf.)– lingula p. sin.
• segments (segmenta bronchopulmonalia)– 10 on the right– 10 on the left (sometimes 8)
• I+II fused, VII missing in 90%
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HILUM PULMONISHILUM PULMONISLeft lung Right lung
BAV
ABV
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Lungs – impressionsLungs – impressions• sulcus arteriae subclaviae (facies mediastinalis)• impressio costae primae (margo anterior)• impressiones costarum (facies costalis)• impressio cardiaca (facies mediastinalis)
Left lung: all on facies mediastinalis• sulcus aorticus• impressio oesophagea• sulcus venae brachiocephalicae sinistrae
Right lung: all on facies mediastinalis• sulcus venae cavae superioris• sulcus venae azygos (!correctly s.v. azygoi !)• sulcus oesophageus
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SegmentsSegments right lung (apalmsmalp) left lung (apasismalp)
Abb. Segmentum No. of segment
Lobe
AP apico-posterious
I + II upper
A anterius III
S lingulare superius
IV
I lingulare inferius
V
S superius VI lower
M basale mediale
VII
A basale anterius
VIII
L basale laterale
IX
P basale posterius
X
Abb. Segmentum No. of segment
Lobe
A apicale I upper
P posterius II
A anterius III
L laterale IV middle
M mediale V
S superius VI lower
M basale mediale
VII
A basale anterius
VIII
L basale laterale
IX
P basale posterius
X
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Lung segmentsLung segments
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Segmenta bronchopulmonalia
Pulmo dexter, lobus superior
Segmentum apicale [S I]
Segmentum posterius [S II]
Segmentum anterius [S III]
Pulmo dexter, lobus medius
Segmentum laterale [S IV]
Segmentum mediale [S V]
Pulmo dexter, lobus inferior
Segmentum superius [S VI]
Segmentum basale mediale; Segmentum cardiacum [S VII]
Segmentum basale anterius [S VIII]
Segmentum basale laterale [S IX]
Segmentum basale posterius [S X]
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Segmenta bronchopulmonalia
Pulmo sinister, lobus superior
Segmentum apicoposterius [S I+II]
Segmentum anterius [S III]
Segmentum lingulare superius [S IV]
Segmentum lingulare inferius [S V]
Pulmo sinister, lobus inferior
Segmentum superius [S VI]
Segmentum basale mediale; Segmentum cardiacum [S VII]
Segmentum basale anterius [S VIII]
Segmentum basale laterale [S IX]
Segmentum basale posterius [S X]
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Blood supply of lungs – functional circuitBlood supply of lungs – functional circuit
• right heart ventricle (deoxygenated blood) → truncus pulmonalis → arteria pulmonalis dx.+ sin. → branching correspond to bronchi– left hyparterial bronchus, right eparterial bronchus
• elastic arteries– low-pressure vasculature 25/5 Torr– smooth muscle cells in fetus, in adults since < 1 mm
→ capillaries (continuous) → oxygenated blood→ venules independent on arteries in septa between
lobules→ 4 venae pulmonales (2 right and 2 left) → left heart
atrium
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BloodBlood supply of lungs supply of lungs functional circuit functional circuit
• arterio-venous anastomoses
• arterio-arterial anastomoses
• veno-venous anastomoses
• during hypoxia fastly growing arterial smooth muscle → hypertrophy of right ventricle
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Vascular supply of lungs – nutritive circuitVascular supply of lungs – nutritive circuit
• aorta thoracica → rami bronchiales– 1 right – usually from a. intercostalis tertia– 2 left – directly from thoracic aorta
→ along bronchi as far as bronchioli respiratorii– (rami bronchiales accessorii within lig. pulmonale)
• venae bronchiales– deep system opening into vv. pulmonales– superficial system drains blood from extrapulmonary
bronchi, pleura and hilar lymphnodes → vv. pulmonales or v. azygos / hemiazygos accessoria
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Lungs – lymph drainageLungs – lymph drainage• superficial subpleural plexus• deep plexus around bronchi and vesselsLung alveoli have no lymph vessels in their walls • nodi lymphoidei intrapulmonales → n.l.
bronchopulmonales → n.l. tracheobronchiales inferiores (both lungs except of three left upper segments I+II, III) → n.l. tracheobronchiales sup. dx. → truncus bronchomediastinalis dx. → angulus venosus dx. → v. brachiocephalica dx.
I+II, III segments on the left – directly into n.l. tracheobronchiales sin. → truncus bronchomediastinalis sin. → ductus thoracicus → angulus venosus sin. → v. brachiocephalica sin.
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Lungs – innervationLungs – innervation
• nn. vagi both sides
viscerosensory + autonomic parasympathetic stimuli
• truncus sympathicus
autonomic sympathetic stimuli
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Tracheobronchial tree (Tracheobronchial tree (Arbor alveolarisArbor alveolaris))
• dichotomic branching
• from bronchioli respiratorii onwards
• 17th-23rd order
• functionally respiratory compartment
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Tracheobronchial tree (Tracheobronchial tree (Arbor alveolarisArbor alveolaris))• respiratory bronchioles (bronchioli respiratorii) 17th-19th order (originating by 17th branching)
– pulmonary alveoli evaginate from their walls– 19th order forms lobulus pulmonis primarius (8 primary
lobuli together form one secondary)• alveolar ducts (ductus alveolares) 20th-22nd order
– pulmonary alveoli evaginate from their walls– at the end of 3rd orderalveolar duct there is atrium
(atrium), divided by last, 23rd branching into two:
• alveolar saccules (sacculi alveolares) 23rd order
– evaginate only into:• pulmonary alveoli (alveoli pulmonis)
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Respiratory bronchioliRespiratory bronchioliBronchioli respiratoriiBronchioli respiratorii
• diameter < 0,3 mm
• simple ciliated cuboidal epithelium
• branching of pulmonary alveoli
• continue into alveolar ducts
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Lung alveoliLung alveoliAlveoli pulmonisAlveoli pulmonis
• 200 μm size, polyedric, thin-walled
• alveolar mucosa = respiratory epithelium
• alveolar septum
• alveolar pores (Kohn)
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Alveolar mucosaAlveolar mucosa• pneumocytus typus I (pneumocyte type I,
type I alveolar cell; membranous p.)• 95% of mucosa• flat, thin (25 nm)• organels around nucleus• pinocytic vesicles
• pneumocytus typus II (pneumocyte type II, type II alveolar cell; granular, spetal, great alveolar cells)
• ovoid shape with microvilli• secretory structure (Mit, GER, GA)• lamellar bodies (1,5 μm) = surfactant• proliferate and differentiate (recovery of mucosa)
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Interalveolar septumInteralveolar septumSeptum interalveolareSeptum interalveolare
• cells• fibroblasts (collagen type I and III) – septum cells• endothelial cells of capillaries• alveolar macrophages (macrophaygocyti alveolares)• reticular and elastic fibers
• alveolar pores (pori septales) – 10 μm
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Blood – air barrierBlood – air barrier((Claustrum aerosanguineumClaustrum aerosanguineum))
• alveolar component (alveolar cell layer, lamina pneumocytica)– pneumocytes type I
• basal lamina (lamina basalis)
• endothelial layer (lamina endotheliocytica)– endothelial cells of capillaries
• Whole respiratory surface of lungs = 140 m2
(almost two volleyball grounds )
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Surfactant (Surfactant (SurfactantumSurfactantum))(alveolar „lining complex“)(alveolar „lining complex“)
• surface-active-agent
• lowers surface tension of pulmonary alveoli
• prevents from collapsing during expiration
• watery hypophasis and lipid epiphasis (dipalmitoyl lecithin)
• resorption and recovery by alveolar cells
• enters into respiratory tract → bronchoalveolar fluid
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Defense mechanismsDefense mechanisms
• nasal apertures – mucus, nasal cartilages, hairs of veostibule of nose (vibrissae)
• ciliated epithelium (mucocilliary transport)• alveolar macrophages (= dust cells)• lymph nodes in the wall• intra-epithelial dendritic cells• T and B lymfocytes (IgA)• antimicrobial substances in mucus (lysosym,
defensins, surfactant protein A,D)
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Lungs – clinical examinationLungs – clinical examination
• inspection, percussion, auscultation, palpation
• X-ray, CT
• bronchoscopy (rigid, flexibile)
• bronchography
• spirometry (vital capacity of lungs)
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A-P and A-P and laterallateral X-ray of lungs X-ray of lungs
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CTCTof of
thoraxthorax
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Bronchogram
Bronchogram
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Lungs – clinical unitsLungs – clinical units
• atelectasis
• embolia
• bronchiectasis
• fibrosis
• lung oedema
• RDS (IRDS), ARDS
• emphysema
• tumors, inflammations (e.g. TBC)
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Kartagener syndromeKartagener syndrome
• missing movement of cilia
• molecular defect in ciliar mobility apparatus
• chronic pyogenic rhinitis and sinusitis
• bronchiectasis
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Cystic fibrosis (muCystic fibrosis (muccoviscidosis)oviscidosis)
• insufficient hydration of mucous layer → increased viscosity
• decrease of periciliary layer of fluid → missing free space for ciliar movement → mucus rests directly on epithelium
• clogging of bronchi with mucus → chronic inflammation + bronchiectasis → respiratory insufficiency
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Lung tumorsLung tumors
• squamous cell carcinoma– effect of smoking– arises from metaplasis of respiratory
epithelium into non-keratinized stratified squamous
• small cell lung carcinoma– very malign tumor
• neuroendocrine tumor (carcinoid) – may be hormonally active
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SmallSmall cell lung carcinomacell lung carcinoma
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PleuraPleura
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Parietal + visceralParietal + visceral pleura pleuraPleuraPleura parietalis et visceralis parietalis et visceralis
• serous membrane– mesothelium (simpler flat)– tunica serosa– tela subserosa
• pleura visceralis
• pleura parietalis– pars costalis, diaphragmatica, mediastinalis
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PleuraPleura
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PleuraPleura
• cupula pleurae – reinforced by membrana suprapleuralis Sibsoni– lig. scalenopleurale, lig. vertebropleurale,
transversopleurale + m. scalenus minimus Sibsoni, lig. costopleurale
• recessus pleurales:– costodiaphragmaticus (puncture)– costo-, phrenico- a vertebromediastinalis
• lig. pulmonale• cavitas pleuralis• liquor pleurae• pneumothorax (external x internal)
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PleuraPleura
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Left pneumothoraxLeft pneumothorax
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Parietal pleura – supplyParietal pleura – supplyArteries:• a. subclavia → a. thoracica interna → a.
musculophrenica + aa. intercostales ant.• aorta thoracica → aa. intercostales post. Veins: thoracic wall veinsLymph: n.l. intercostales, parasternales,
diaphragmatici, mediastinales posterioresNerves:• nn. intercostales (pleura costalis + peripheral
pleura diaphragmatica)• n. phrenicus (pleura mediastinalis + central pleura
diaphragmatica)
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Pleura visceralis – supplyPleura visceralis – supply
• corresponds to lung supply
arteries: rr. bronchiales
veins: vv. bronchiales
lymph: see lungs
nerves: only autonomic nerves around vessels, around hilum from n. vagus
!!! Visceral pleura is not painfull !!!
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Projection of pleura and lungsProjection of pleura and lungs
• projection of lungs 1-2 intercostal space higher lower compared to pleura
• 10 lines on thorax
• area interpleuralis superior (thymus)
• area interpleuralis inferior (heart)
puncture: 7.-8. intercostal space in posterior axillary or scapular line by upper costal margin
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Projection of Projection of lungs and lungs and
pleurapleura
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Respiratory musclesRespiratory muscles
• inspiratory– main: diaphragm, mm. intercostales externi, (mm. scaleni,
mm. levatores costarum)– auxiliary: m. pectoralis major + minor, m. latissimus dorsi, m.
serratus anterior + post. sup., m. sternocleidomastoideus, m. subclavius, (m. sternothyroideus, m. sternohyoideus) – orthopnoic posture
• expiratory– main: mm. intercostales interni (+ intimi, m. subcostales)– auxiliary: m. rectus abd., m. obliquus abd. ext. + int., m.
trasnversus abd., m. serratus post. inf., m. transversus thoracis, (m. quadratus lumborum), m. levator ani
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MediastinumMediastinum
• anatomical division:– upper– lower (anterior, middle, posterior)
• surgical division (many ): e.g.– anterior– posterior
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Mediastinum superiusstructures in 5 layers ventrodorsally:
1. thymus, insertions of mm. sternothyroideus et sternohyoideus, vasa thoraciaca int. + branches
2. layer of veins: vv. brachiocephalicae (plexus thyroideus impar, v. intercostalis sup. sin.) join ito v. cava sup., ductus thoracicus, nn. phrenici
3. layer of arteries: arcus aortae + branches
4. organs: trachea + bifurcation (at level of vertebra T4), bronchi principales, oesophagus + nn. vagi, rr. cardiaci, n. laryngeus reccurens sin., nodi lymphoidei tracheobronchiales, nodi lymphoidei paratracheales, membrana bronchopericardiaca
5. truncus sympathicus dx. et sin., nn. cardiaci, nodi lymphoidei juxtaesophageales, m. longus colli
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Mediastinum inferiusMediastinum inferiusMediastinum inferius anterius• ligg. sternopericardiaca • nodi lymphoidei parasternales, prepericardiaci (= "n.l. mediastinales posteriores") • vasa thoracica int. + branches • m. transversus thoracis
Mediastinum inferius medium• heart in pericardium • aorta ascendens + truncus pulmonalis • v. cava sup., v. cava inf. (+ ostium of v. azygos) • nn. phrenici, vasa pericardiacophrenica • plexus cardiacus • vv. pulmonales • nodi lymphoidei pericardiaci laterales
Mediastinum inferius posterius• oesophagus + plexus oesophageus • truncus symphicus + nn. splanchnici (major, minor, imus) • nodi lymphoidei prevertebrales, juxtaesophageales (= "n.l. mediastinales posteriores") • ductus thoracicus • v. azygos, hemiazygos et hemiazygos accessoria (+ tributaries) • aorta thoracica + branches
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Mediastinum Mediastinum posteriusposterius