ThE CIBA COLLECTIONOF MEDICAL ILLUSTRATIONS
Volume 7
Respiratory System
A compilation of paintings depicting anatomy andembryology, physiology, pathology, pathophysiology,and clinical features and treatment of diseases
Prepared by
Frank H . Nester, M.D.
Edited by
Matthew B . Divertie, M.D .
Alister Brass, M.D .
Directing Editor
Commissioned and published by
CIBA
Contributorsand ConsultantsThe urtift, editors, artd publishers express theirappreciation to the fn!lawtng ruethorities for theirgemrout cvllubx'ralion:
Associate Professor o Medics neMu rray D Al to se, M.D.~lssocCase Western Reserve UniversitYSchool of Medicine ;Director Pulmonary DivisionCleveland Metropolitan General Ho5pitalCleveland, Ohio
Mary Ellen Avery, M .D .Thomas Morgan Rotch Professor of Pediatrics,Harvard Medical School ;Physician-in-Chief,The Children's Hospital Medical Center,Boston, Massachusetts
Professor of M ici rye and Chief.Pulmonary
Howard A Buechner, M. D
Disease Section Louisiana BranUniversity
fMeicine in New Orleans ;hoof oSenior Visitin Physician,Charity Hosital n Louisiana 1New Orleans, Louisiana
Neil S. Cherniack, MiD .Professor of MedicineCase Western Reserve UnivcrsicySchool of Medecine .Cleveland, Ohio
Hyun Taik Cho, M. D .Senior Instructor of Surgery,Mount Sinai School of Medicine ofThe City University of New York ;Assistant Arcending Surgeon,Beth Israel Medita[ Center,New York, New York
Jacob Churg, M. D .Professor of Pathology,Mount Sinai School of Medieine ofThe City University of New York ;Chief, Division of Renal Pathology.The Mount Sinai Hospital,New York, New York
Robert W. Colman, M .17 .Professor of Medicine and Pathology ;Chief, Coagulation Unit,The University of PennsylvaniaSchool of Medicine .Philadelphia . Pennsylvania
u
. Crelin,
+ +
.
i*Professor and hi Section n Anatomy,
Department o Bur e rYChairman Human Growth anDevelopment Btu UnitYale University cltonl of
eicintefew Haven, Connecticut
Matthew B. Divertie, M . D .Professor of Medicine, Maya Medical School ;Cansulcanr, Division oFThoracic Diseases,Department of Internal Medicine andSection of Respiratory Care,Deparrment oFAnesthesiology, Maya Clinic,Rochester, Minnesara
u
steinCardiovascular-Pulmonary Division,The University o PennsylvaniaSchool of MedicinePhiladelphia, Pennsylvania
Alfred P Fishman, M .DWilliam Maul Mcasey Professor of Medicine ;Di retcar, Card iovasrular-Pulmonary Division,Department of Medicine ;Principal Investigator, Lung Center,The Universiry of PennsylvaniaSchool of Medicine,Philadelphia, Pennsylvania
Albert Haas, MiD .Professor n Ex rirneritalRehabilitation Medicine •iDirector, Pulmonary Services 1ear
nrtmeo f RehabilEtarLon Medicine.Ie York University &hail n Medicine,
New York , New York
Henry O. Heinemann, M.D.*
Professor of Medicine,Carnell University Medical College,New York, New York
John Franklin Huber, M.D., Ph .D.
Professor Emeritus of Anatomy .Temple University School of Medicine,Philadelphia, Pennsylvania
Roland I-1 . Ingram, Jr., M,D .Associate Professor of Medicine,Harvard Medical School ;Director, Respiratory Disease Division,Peter Bent Brigham Hospital,Boston, Massachusetts
j Dec a
7
aa~
ire
1
gar Professor of Physiology,The UiliYersit of Penn lvinia
pool o Medicine,Philadelphia Pennsylvania
Jose
17 a
.s lore Division f Pulm rya Diseases
Mount cnai Medical CenterMiami Peach Florida ;Itet rac tor, Detarr me nt of Medicine }Univ rsir f Miami School of Medicine .Miami Florida
Victor J . Marder, M.D.Professor aF Medicine ;Co-Chief, Hematology Unit,University of RochesterSchool oFMedicine and Dentistry,Rochester, New York
Edward D . Michaelson, M .D .Associate, Division of Pulmonary Diseases,Mount Sinai Medical Center,Miami Beath, Florida
Professor and Vice ChairmanWallaceT. Miller, MD.
,Department oIRadiology,
School of Medicine ;Chief, Chest Division
of he University of Pennsylvania .Hospital ~r y.lvania,Philadelphia F PcnosYlvanLa
Roger S. Mitchell, M .D.Professor Emeritus of Medicine,University of Colorado School of Medicine,Denver, Colorado
W. Spencer Payne, M .D .Professor of Surgery, Mays Medical School ;Consultant in Thoracic andCardiovascular Surgery, Mayo Clinic,Rochester, Minnesota
Giuseppe G. Picts, M . D .Professor of Pathology,The University of PennsylvaniaSchool of Medicine,Philadelphia, Pennsylvania
Lynne M. 1S . Burt Wol ach Professor of Pathology,Harvard Medical SchoolPatholo isr-in- hi fThe Children's Hospital Medical Center,Boston I assachus trs
Jatria
ail
iAssoc late Pro essor o Medicine .,University f iami hoof of l Medicine,~Miami . Florida
UnaS. Ryan, PhDAssociate Professor n MedicineUniversity n Miami School o MedicineMiami, Florida
Marvin
acnetDirector Medical Services,Mount Sinai Medical Center,Miami Beach, Florida ;Professor n MedicineUniversity o Miami School of Medicine,Miami Florida
are
tY rs r.
.Associate Pro lessor ofMedicine an Microbiology ;Direcror Infectious Diseases .t
Louisiana Stare UniversityMedical rarer in New OrleansMew Orleans, LouisianaNe
Max L. Som, M .D .meritug Professor of tola n olo
dicine ofMount Sinai school of Iii~of New forh
t~e City University
tAttending Head and Neck Surgeon o serviceBetll Israel HospitalN r York, New York
D . Eugene Strandness, ,]r., M.D .Professor of Surgery,Department of Surgery,University of WashingtonSchool of Medicine,Seattle, Washington
Morton N. Swartz, M.D.Professor of Medicine,Harvard Medical School ;Chief, InfeCcious Disease Unit,Massachusetts General Hospital,Boston, Massachusetts
.
∎
Aloin S . Teirstein, M.D.Director, Pulmonary Division ;Florette and Ernst Rosenfeld andJoseph Solomon Professor of Medicine,Mount Sinai Schavl vfMedicine ofThe City University of New York,New York, New York
Professor ofSurgery, College ofMedicine JosephJ
. Timmes, M .D .
an Dentistry o New Jersey,Newer Medical SchoolDi rector afSurgery, Mei cal net r
jersey it New Jersey
Attending Physician,Department Milton H
. Uhley, MiD .
n Medicineors-Sinai Medical Center
Los Angeles, California
Earle
Weiss,
.Director Division o ResPirato DiseasesSaint Vincent Hospital ;}Professor o Me icineUniversity o Massachusetts Medical School .Worcester Massachusetts
William Weiss, MiD .•Professor of Medicine ;
Director, Division of ccuparional Medicine
Hahnemann Medical College and Hospital .
Philadelphia, Pianys lvania
William Wolff,
1
Professor of Clinical Surgery .
Mount Sinai choo1 of Medicine
The it niversir o New York ;}
Former Director o SpurgerY}
Beth Israel Medical Center
New for New Y'e rk
wiri
Director , Department of Medicine,
Pennsylvania Hospital ;
Professor o Medicine,
The LlniversitY of Pennsylvania
school o brie c e
Philadelphia, Pennsylvania
Morton M . Ziskind, MiD .
Professot of Medicine ;
Director, Pulmonary Diseases tion
Department o Medicine
Tulane University School of Medicine,
New Orleans Louisiana
Contents
SECTION I
Anatomy and Embryology
Pukr
Anatomy
Respiratory Sysrem Plate 1 3
Bony Thorax Plate 2 4
Rib Characteriscics and Coscv-
verrebral Articulations Plate 3 . . -
5
Anterior Wall ofThorax Plates 4-G . . G-8
Dorsal Aspect ofTharax Pirates 7-8 . . 9-1D
Lateral Aspect of Thorax Plate S . . . .
10
Intercostal Nerves and Arteries
•
• • • f f ! 1 1 i i i 1 1
Diaphragm (Viewed from Above)
PlatelO -------
12
Topography of Lungs Plates I1-I2 . . 13-14Medial Surface of Lungs Plate 13 . . .
15
Bronchopulmonary Segments
Pirates I4-1S . . . .1G-17
Relations of Trachea and Main Bronchi
P!aleIG - .-- .-
18
Bronchial Arreries Plate I719
Mediastinum Plums IS-I920-21
Innervarion of Trac heabronc hia! Tree
Plate2Q---------- . . .
22
Structure of Trachea and Major
Bronchi
23
Intrapulmonary Airways Plate 22 . . .
24Structure of Bronchi and Bronchioles ;
Light Microscopy PkY1e2325
Ultrastructure nfTracheal, Bronchial
and Bronchiolar Epithelium
Branchial Submucosal Glands
+ . . . 1 4+ 1 1 1 i . . . .
27
Intrapulmonary Blood Circulation
Ulrrasrrucrure o£ Pulmonary Alveaie
and Capillaries Plate 27 29
Type ! I Alveolar Cell and Surface-
Active Layer Plate 28 . .'+ .+ .., .
30
Pulmonary Vascular Endothelium
Plate 29 31
Lymphatic Drainage of Lungs andPleura Plates30-31 32-33
28
SEC-rioN 1 (continued)
Page
Embryology
Development of Respiratory System . . 34-43
Developing Respiratory Tracy at 4za 5 Weeks Plate 32 34
5a~itralSect ion ; Bronchi and Lungsar S in 6 Weeks FIe#e33 35
Developing Respiratory Tract at 6
ro 7 Weeks Plate 34 iG
Larynx, Tracheobronchial Tree and
Lungs at 7 to 10 Weeks Place 35 . .
37
Sagittal Section at G co 7 Weeks
Plate3G 38
Transverse Sections at 5 to 8 Weeks
Plute37 39
Innervation of Tongue, Neck and
Diaphragm at 5 rv G Weeks ;
Origins of Diaphragm Plate 38 . .
40
--Terminal Air Tube at 20 and 24
Weeks Pl~tte39 41
Alveolar-Capillary Relationships at
8 Years Plate 40
Surfactant Effects P1ate42
SECTION 11
Physiology
Pulmonary Mechanics and Crds
Exchange 47-71
Muscles of Inspiration and
Expirarion Plate Y 47Spirometry Plate 2 48
Determination of Functional
Residual Capacity Plate 349
Forces During quiet Breaching
+ 1 + 1
Measurement of Elastic Properties
of Lung Plate 5
Surface Forces in Lung Plate G . . .
Elastic Properties of Respirawry
System Plate 7
Distribution of Airway Resistance
Patterns of Airflow P/ate 9
-Expiratory Flow-Volume Curses;
Isovolume Pressure-Flow Curves ;
Determinants of Maximal
Expiratory Flow Plate IQ
Forced Expiratory Vital Capacity
Maneuver; Maximal Expiratory
Flaw-Volume Curves Plate I I . . . 1
4243
50
5153
54
5556
SECTioiv I1 (continued)
Page
Work o£ Breach i ng Plate 12bU
Pleural Pressure Gradient ; Closing
Volume P1a#e 13 Gl
Vascular Pressure in Systemic and
Pulmonary Circulations ;
Distribution of Pulmonary Blood
Flow Plate I4 62
Pulmonary Vascular Resistance
P1ateIS 63
Transfer of O~ and COE Between
Alveolar Air and Capillary Blood
Pt ! f I+ T 1+ 1 1+ 1 1+ 1 1 1 1 1 + Y I F
65
Blood Gas Relationships During
Normal Ventilation and Alveolar
Hypoventilation Plate 27GG
Ventilation-Perfusion Relationships
67
Shunts (Normal and Abnormal)
Plate 19 69
Oxygen Transport Plate 2070
Regulation of Acid-Base Balance
Plate21 71
Pulmonary Response to Oxidant
Injury Platt 22 72
Inactivation (Serotonin Metabolism)
Plate 23
Activation of Precursors (Renin-
Angiotensin 5yscrln) Flaie 24 , . . .
74
Control and Disorders of Respiration . 75-82
Chemical Control of Respiration
+
i! 7+ f l+ 1 1+ Y+ i . .
75
Neural Control of Breaching
PlatezG 76
Respiratory Response ca Exercise
!
+,+ 1 1+ Y i+ l i .
78
Effects of High Altitude on
Respiratory Mechanism Plate 2$
79
Hyperventilation and
Hypoventilaripn Pfute 29SU
Periodic Brearhing (Cheyne-Stokes)
4+!++ 1++ 1+ I l i i+ i 1 1 i i
1
Sites of Pat hologir Disturbances in
Control of Breathing Plate 31 . .
73
SIcrioN III
57Radiology
Roentgenologic Examination of
58
Lungs 85-103
SECi'iUiv III (continued)
Page
Posteroanterior View ; Left Anterior
Oblique View Pirate I SS
Lateral View; Right Anterior
Oblique View Plate Z
-Lordotic View Flute 3
Lateral Decubitus View Plate 4 . . .
-Penetrated Grad Roentgenograms
Tomography Plate G 90
91Bronchography : Technique Plate 7
-Right Bronchial Tree as Repealed by
Bronchograms P/ate S 92
Left Bronchial Tree R5 Revealed 6y
Bronchograms Plate 9
Pulmonary Angiography Pluto IO .
Radioactive Scanning Methods
P1uteIl
Perfusion and Ventilation Scans
i
. a a + • • • + + 1 a + 1 + + • + + a + 1 1
-Patterns of Lobar Collapse; Right
Lung Plate 13
Patterns of Lobar Collapse ; Left
Lung Plate~4 99
Consolidation Patterns of Each
Segment of Lungs Plate 15
Alveolar Patterns of Pulmonary
Disease Plate IG
Interstitial Patterns of Pulmonary
Disease P/atel7
SECTION IV
Diseases and Pathology
Congenital Malformations
Congenital Deformities of Thoracic
Cage Plate I 107
Kyphoscoliosis Plates 2-3108-109
Congenital Diaphragmatic Hernia
+ T T !, 4+ • 1+ 1 1 a+ I l i i
i
Tracheoesophageal Fistula and
Tracheal Anomalies Plate 5111
Pulmonary Agenesis, Aplasia and
Hypoplasia Plate G 112
Congenital Bronchogenic and
Pulmonary Cysts Plate 7113
Bronchopulmonary Sequestration
Plate 8 i14
Congenital Lobar Emphysema
$6
87
88
93
94
95
96
98
101
iaz
103
SECTLON IV (continued)
Discuses of the Airuays
Laryngeal Granuloma and Tracheal
Stenosis Plate IO
Tracheal Resection and Anastomosis
Plate 11 . + l i • I • l a l l+ I I
I l+ l a l a
Plastic Reconstruction of Trachea
to i
+ 1+ 1+ • I + 1 1 1 1+ 1+ • 1 • 1+ 1+
118
Branchial Asthma 119-135
Extrinsic Allergic Asthma: Clinical
Features Plate I3 119
Intrinsic Asthma : Clinical Features
Plate 14 120
Postulated Mechanisms of Airway
Hyperreactivity Plate IS121
Mechanism of Type I
Hypersensitivity Plate 16122
Catecholamine Action an tr and R
Receptors Plate 27 123
Theory of Catecholamine Effects and
fl-Adrenergic Blockade Plate I8 . . 124
Corritosceroid Actions Plate 19 . . 125
Common Precipitating Factors
Plate2a 126
Pathology of Status Asthmaticus
Plate 21 127
Differential Diagnosis Plate 22 . . . I2$
Sputum Prate 23 129
Management of Acute Asthmatic
Attack Plate 24 13 t
Blood has and pI--I Relationships
Pirate 2S 132
General Management Principles
Plate 2d 133
Skin Testing for Allergy ;
Hyposensirizacian Plate 27135
Chronic Obstructive Pulmonary
Disease (COPD) I3G-153
Interrelationship of Chronic
Bronchitis and Emphysema
P /ate 28 • F • 1+ f 1 4 I I ••+ + I F 1 I ++ F+
136
Chronic Bronchitis P/ate 29137
Centriacinar and Panacinar
Emphysema Plates 34-32138-140
Pulmonary Function in Obstructive
Disease Plate 33 141
Pursed-Lip Breathing in COPD
Plate 34 142
Effect of Emphysema on
Compliance and Diffusing Capacity
Plase35 - •- ---
143
Page
116
117
SEC71aN IV LCOriCinuedJ
Page
Cor Pulmonale Due to COPD
Plate 36 144
Small Airway Disease and
Smoking Pdules 37-38145-I46
Small Airway Disease and Ural
Infections Plate 38 146
Hypothesis of the Role of
al-Antitrypsin Plate39147
The Pink Puffer Plate 40148
The Blue Bloater Plate 4I149
Roentgenograms in CAPD
Plate 42 150
Genera! Measures in Management
oICOPD Plate 43 ••••••••• .
151
Specific Measures in Management
of CAPD Plate 44 152
Emphysematous Cyst Plate 45 . . . 153
Bronchiectasis Plates 46-47154-155
Cystic Fibrosis of the Pancreas
Plates 48-49 - - - 15G-I57
In trutboracic Tumors
Classification of Bronchogenic
Carcinoma Plate Sd 158
Squamous Cell Carcinoma of Lung
Plate 51 159
Large Cell Anaplastic Bronchogenir
Carcinoma Plate 52 160
Small Cell Anaplastic Bronchogenic
Carcinoma Plate 53 161
Adenacareinoma of Lung Plate 54 . . 162
Pancoast's Syndrome Plate 55 . . . .
163
Superior Vena Cara Syndrome
P/atei6414 .••••••• .
164
Lymphangitic Spread and Cavirarlan
of Lung Cancer PGxte 57165
Endocrine Manifestations of
Bronchogenic Carcinoma Plate 58 166
Neuromuscular and Connective Tissue
Manifestations of Bronchogenic
Carcinoma Plate 59 167
Merasratic Carcinoma to Lung
j:late 60 168
Alveolar Cell Carcinoma Plate 61 . . , 169
Bronchial Adenoma Plate 62170
Benign Tumors of Lung P/ate 63 . . . . 171
Tumors of Mediastinum Plate 64 . . , 172
Mesothelioma of Pleura Plate GS . . . 173
Infectious Diseases of the Lung
Pneumoc occal Pneumonia
. . . 175-17b
~ErrLoN
Klebsiella
IV (continued)
(Friedlander's) Pneumonia
Prr~r
SECTION IV (continued)
Various Mineral Pneumoconioses
SECTION
Rupture
IV (continued)
of Trachea or Major Bronchi
Purr
Plate GS 177
Plate ICJ3 214
Plate 129 , 241
Staphylococcal Pneumonia Plate G9 1713
Irritant Gas Effects on Lungs Subcutaneous Emphysema; Traumatic
PlateI04 215
Asphyxia Plate 230 242Influenza Virus and Its Epidemioiagy
Flare 70 179
Hypersensitivity
. . . . . . . . . . . . . . . . . . .
Pneumonitis
. .
Ogen Pneumothorax Plate 131 • . . • • 243
(nfXuenzal Pneumonia Plate 71 . . . 181
FIatQS 1U5-IU6 21G-217 Tension Pneumothorax Plate 132 , . . 244
Varicella Pneumonia Plate 72
. . . 132
Pulmonary
Thromboembolic Disease
Hemothorax Plate 133• • • 245
Cytomegalovirus PneumoniaCascade of Clotting Factors and Sites Chylothorax Plate 134 246
183
of Action of Heparin and WarfarinPulmonary Contusion Plate 135 . • . . 247
Plrxte107 . . . . . . . . . . . . . . . . . . . . . 219Legionnaires' Disease Plate 74 . . . . 184 Posttraumatic Pulmonary
Pneumocystis Carinii PneumoniaClinical Manifestations of Lei Vein
Insufficiency (Shock Lung)Thrombosis Plate I08 220
Plate 75. . . . . . . . . .
Platel3G . . .
. 21)
Mycoplasmal Pneumonia (PrimaryFibrin Degradation
Diagnosis of187
Plate 2019
Products in
Pulmonary EmboliDiseases of Unknown Etiology
221 Hyaline Membrane DiseaseAtypical Pneumonia) Plate 76 . . .
Lung Abscess Plates 77-78 lSH-139 Plates 1.37-139 250-252. . . . . .
Actinomycosis Plate 7) 190
Vein
Phlebography
Thrombosis
for Diagnosis of
(Venography)
LegIdiopathic Diffuse Interstitial
Nocardiosis Plate 80 , 191
Plate I1U .
4
zzz Pulmonary Fibrosis (Hamman-Rich
Disease) Plate 24a 253
Histoplasmosis Plates 81-82 192-193Radioactive Fibrinogen Scan tor
Diagnosis of Lei Vein Thrombosis Sarcoidosis Plats 14I-I42255-25G
Coccidioidomycosis Pluto 83 1)4Platelll 223
Idiopathic Pulmonary Hemosiderosis
North
Plate
American Blastomycosis
84 195Ultrasound in Diagnosis of Acute
Platel43 257
Venous Thrombosis Pirate 112 . . . . 224
Alveolar Proteinosis Plate 144 258
South American Blastomycosis
196 Plethysmography in Diagnosis of Leg
Connective Tissue DisordersPla1e85
Vein Thrombosis Pinto I1,3 225 Lung Involvement in Rheumatoid
Cryptococcosis (Torulosis) Pfute 8G . . 197Pulmonary Embolism . . . . . . . . . . 22G-235
Arthritis Plate 145 259
Aspergillosis Plate 87 198. . . . . . . . . . . .-Sources of Pulmonary Emboji Lung Involvement in Progressive
Tuberculosis 199-207 PIateI14 226
Systemic Sclerosis Plate T4G 26()
Dissemination
Tuberculosisof Predisposing Factors for Pulmonary Lung Involvement in Systemic Lupus
Plate 88 . 199
Embolism Plate IIS .+ .+ . . . . - .
227
Erythematosus Plate 147 261
Evolution Pluto 8)ofTubercle 200. .
. Embolism oFl.esser Degree Lung Involvement in
Initial Tuberculous VfTrhour Infarction Plate 116 223
Dermatomyositis and Polymyositis(Primary) . . . .
Complex Plate 90 ?dl
Massive Embolization Plate I17 229
Plate I-'FS 262. .
Aolyarteriris Nodosa, Wegener'sPulmonary Tuberculosis : Pulmonary infarction Flute 118 230. .
Progressive Pathology Plan )I . . , 202 Granulomatosis and AllergicChronic Effects Pulmonaryof
Pulmonary Tuberculosis : Extensive Granulomatosis Plate 149 263
Cavitary Disease Pluto 92 . . . . 203Embolism (Cor Pulmonale)
. . . . . . . .
Plutell) 231Miliary Tuberculosis Plate 93 . . . . 204
Medical andProphylaxis Thcrapy
Tuberculin 205Towing Pluto 94 . . . . . Plate I?0 2325ECT10N V
206Sputum Examination Plate 95 . . . Tests for Monitoring Anticoagulant
Culture Plate 96 Plate 121 233-Sputum . . . . . . . 207
Therapy . . . . . . . . . . . . . Diagnostic and Therapeutic Procedures
Silicosis
Inha/ation Diseases of/be Lung
Pdute 97 208
Pulmonary
Surgical Defenses
Embolism
Against Massive
Place 122Tests of Pulmonary Function
4. . 24
Plates 1-2 2G7-2G$
Extravascular ofSilicotuberculosis ;
Pneumoconiosis
Rheumatoid
Plate 98 209Emboli
Sources Pulmonary
Plate 123Psychotherapy and
235
of $ranchodilator
Administration
Therapy
Coal Worker's Lung Plate 99Plrlninnary Ede ma
210Pulmonary Edema Plates 124-125 236-237
Asbestosis Plate 100 21!Upper Airway Obstruction ;
Thoracic Trauma Heimlich Maneuver Pluses 5-G 271-273Reactions
Mixed Dusts
Produced
Plan
6y Metals
101
and
212 Thoracic Cage Injuries Plate 126. . . . 238
Patent Airways Place 7 274
Cadmium Inhalation Effects ; ChronicFlail Chest PIrx1'e 127 239 Endotracheal Intubation Pirate 8 . . . . 275
Beryllium Disease Plate 102 213 Diaphragmaric Injuries Plate 128 . . . 240 Tracheostomy Plate 9 276
;FCPIOrI V (Continued)
Psrgr
~tor6idity of Endotracheal Intubationand Traeheoscomy P1ute IO277mnchofIberscopic Suction andlavage Plate]]278
Vasotracheohronchial SuctionJ1,late 12 1 1 . .. 7 1 1 1 1 1
t
_
279Smnchofiberszopy Plate 13 - . - . . - . - 280Bronchofilaerscopic Views Plate 14 . . 281Vomenclature for Peripheral Bronchi
Plate I5 282Rigid Bronchoscopy Plate IG283[ntroduction of Chest Drainage Tubes
5scrioN V (continued)
PaRr
Underwater-Seal Drainage of Chest ;Heimlich Vale Plate 18285
Postural Drainage Plates 19-20 . . 28G-2$7Breathing Exercises Plate 21 . . . .
288Arterial Blood Gas Analysis
P/ate22 . . .289Oxygen Therapy in Acute Respiratory
Failure Plate 23 -291Methods of Oxygen Administration
.Ambulatory and Home Use of oxygen
JP Izte
. . . . i l i i l i 1 f I f i 1 i 1 F# F t
293Mechanical Ventilation Plate 26 . . . . 294
zsa
5ec°riaH V (continued)
Pair
Mediastinoscopy Plate 27295Mediastinotomy P1nte ZS296Pneumonectomy Plates 29-30 . , . 297-298Lobectomy Plate 3 .1 -299Resection and Biopsy Plate 32300Removal of Mediastinal Tumors
Selected References303-3I1
Subject Index313-327
Section I
Anatomy and EmbryologyFrank H. Netter, M.D.
Edmund . relin, PhD. , D4Sc. Pi • . - iJohn Franklin Huber, M.D. , Ph .D. mates 1.1
Lynne 11i. Reid, MD 1 hates i-, 3031
Una S. Ryan, Ph.D. and James W Ryan, M.D , Ph.D. i-iaies 27-29
Earle . Weiss, M111 late 20
SECTION
NJLTE 20
Innervation of Lungs andTracheobronchial Tree
The tracheobronchial tree and lungs are inner-voted by the autonomic nervous system - Threetypes of pathways are involved : rtor rric afferent,
oras al et a ererit and r otic a Brent, Eachtype of fiber is discussed here while rhe neuro-chemical control of respiration is covered in thesccrion on physLology (See pages 75 and 76) .
t1 lotromrc Afferent Fibers . ffercnr fibbersf Itretch retori in the alveoli as well as fiberstornfrom irrirat r t r~ in the bronchi and bron-choi les travel vi the pulmonary plexus tocared~around the tra heal hi furcation and roots of rheclungs) to rhe va us nerve. imilarlY3 fibers from~irritant here tern i rr rhe trachea and Frorri c~tirecetars in the larynx reach the central nervous sYscornvia the va us nerve . her re tori in the carotidand aortic bodies and pressor receptor.n the carotidsinus and aortic arch a1se give rise ro afferentsautonomic fibcrs . Thc fibcrs from rhe carotidsinus and carotid body travel via the 1o sn-pharYn eal nerve, whereas rinse from rhe aorticbody and aaortic arch travel via the vagus nerve .Otherreceptorsin the nose and nasal sinuses givenis to afferent fibers that form parts of rhe trigem--~Trial and lassoFharYn cal nerves . I n addition , rherespiratory centers are controlled ro some extentb im ulses from the hypothalamus arid highercenters as well as from rhe reticular activatingsystem .
Parasympathetic Efferent Fibers . All lparesYrn-arhetic preganglionic efferent fibers to the
tracheobronchial tree are contained in the vagusnerve, originating chiefly from cells in rhe dorsalvagal nuclei that are closely related to the medul-lary centers, ~Th • fibcrs relaY withY resPshort
sr an glionic fibers in the vtcinir}' o or~within the walls of rhe tracheobronchial tree- ThisGras m athetic efferent arhwa carries m tor
tet tilses to rhe smooth muscle and lands of rherracheobrenchial tree . The irepulses are cholin-ergTeal)Y mediated arrd 1'roduce bror chial smo othrnuscle concraccion landular scoredon~ andVas ilation .
S matet/c E eret Fibers, The re-are 1ionic c
~fferent fibers emer re from the sptool~~medulla cord at leve1s T10r T ro T5 or 7 and
ass t the s rn arhetic trunks via white: ramicomrnurricanres. hrhcrs car rY in impulses to thelar nx and uPRr trachea ascend in rhe syrnPa-e}~thetic cru nk and s naFse in rhe cervical sYrnpa-thettc an lra with ost art lrorttc fi be rs to rhosescructures . The remainder sYnaPse rn the upf'erth ra< iart 1 is of rhe s rnathetic trunkswhencc the nsrgartg)ionic fiber ps ass to the lowerl~trachea the bronchi and rhe bronchioles a lar elvia th
ulmanar
le as . The osr air )ionic
2z
From hypothalamicand higher oenters
Descendi ntractsin sPictaltedul lacord
Thoracicspinal medulla(cord)
YmRathetic.r
trunk
Key
ParasyrnRathetic vagus1 efferent fibers~
YmRathetic efferent fibers
Aff creat fibers
A : Adrener is terminals(notepanePf rEne and orePmeRhnne
Cholin r is terminals(acctYicholine)
nerve end in s are a .Ir 'nor k .
m athetic srimu-lacien rea1 . rcs bronchial and bronchiolar sii~ot rhmus 1
inhibits Klan hilar secretion and causesvase c nsrrrctL fl .
Fharniacoto sic studies in )koro that there are
r rp3s fadrerierrrc ' recetars alha and bcta .
The alFha receRtars are located primar .ilY in
smooth muscle an xocrive glands . Beta rece -and e~
l~tors havc e been differenciace }harmacolrmall yintobeto 1 l cat d in rhe hearr anal l et
lcc -avidsi n set ~~th m nsclr rhrou hau c the boil includink
bronchial and vascular smo{ th muscle . General)alPha stimulation is excitatotY . Beta stiniularion
m be inhibitorY relaxation of bronchial smooth
InAervalinn of Tracheobronchial Trac
IesseRhofrtgeaI nerve~
V u nerve lcholiner ic ;motor fibers to smooth muscleand lands ; afferent fibers fromaorta tracheobronchial mucosa,h
and alveoar}
uRerior cervicals mPathetic ganRlion
ymRethetiC nerves
adrener ic)
+efferentnerves fromnose Aridsinuses (viatri eminaland losso-Rhar ngeal nn .
ou hreceptors
Lar nx
44
I mtant receptors
treteI7 receRtors (Hering-Breuer r flex
muscle} r excitatof increase in bath heart rareand farce ot contract~ i on . Bcto stimulation also
rends ro mc
T
i ~bslizc ener
bY 1Ycogenolys s and~Ylipo1ysis . For further discussion of this topis, see
R~a yes 122 and L - .attain tissues comairt ~ both alPha and beta
retePtars . The result of s rimularic n deFends onzhe notare of the stimularin catecholarrriree and
rhe re1atwc PrFr~ rti~~n of rite cue t Pos o f rec eo p-
tots . lri the lun s bet stimulation there aren bcra irece torr hers) carries bronchodilatation
` aland r~ssiblY
~ decreased secrerion of mucusf~
pha
adrenergic strmu arson bY 1'
~harrnacolo gic a entscartses brenchc constriction=
T'NF CIR .•I CpLLECT'I() N, 4'ULUAlE 7
SECTION 1 PLATE 20
Structure of Trachea andMajor Bronchi
The trachea or windpipe passes from the larynxto the level of the fourth thoractc vertebra where it
divides into the two main bronchi that enter theright and left lungs. About 20 C-shaped laces ofplatescartilage support the anterior an lateral walls 0fthe trachea and main bronchi . The posteriorwall--or membranous trachea-is free of cartila e,but interlacing bundles of muscle fibers lie in thisre ion and insert into the posterior ends of thecartilage places .Mucous lands are particularly numerous
posteriorly. Some lie between the cartilage plates .and some are external to the muscle layer withducts that penetrate this layer to open on themucos,al surface . Posteriorly, elastic fiberr aregrouped in longitudinal bundles immediately be-neath the basement membrane of the tracheatepithelium, an these appear to the caked eye asbroad at bands that give a ridged effect to theinner lining ~of the trachea • they are not so obviousanteriorly. The bands of elastic fibers are thinner~`and surround the entire circumference of the lowerarrvrays .
Just above the point at which the main bronchusenters the lung . the cartilage plates come togetherto completely encircle the airway . Posteriorly. theends of the plates meet and the mernbrehear regiondisappears . The Plates are no longer C-shaped butare smaller, more irregular and arranged around thewall . Where the main bronchus divides into lobarbronchi-ac the hilus of the Jung-the places of
rrilagcartilage are large and saddle-shaped to supportthis region of bifurcation .
At the level where cartilage completely sur-rounds the dreumference of the airway, the musclecoat undergoes a striking rearrangement . It nolonger inserts into the cartilage-as in thetrachea-but forms a separate Layer of interlacingbundles internal to it . The airway lumen can now
occluded b contraction of the muscle • but the
Thyroid cartilage
Cricothyroid ligament
Cricoid cartilage
Connective tissuesheath (out away)
lfltercaftila irlou5ligaments
Mucosa showirlIon itudinal folds formedby dense collectionsof elastic fibers
Toupperlobe
Tomiddlelobe
E arterialbronchus
Structure of Trachea and Major Bronchi
Toloverlobe
Ii
intrapulmonary ExtraPulrnonar Y
trachea is never subjected to such sphincteric
(Plate 14) .action .
The right main bronchus is shorter than the leftand angles away from the trachea less sharply thanthe left . Foreign bodies rode more often in theright main bronchus than in the left bronchus .
Lobes and S'err enu . The right lung has threelobes and the left has two, although the lingula ofthe left lung is analogous to the right middle 'obe .
The bronchopulmonary segments are the topo-graphic units of the lung, and are a means oidentifying regions of the lung either radiolo icallor surgically; there are eight bronchopulmonarysegments in the left lung but 10 in the right lung
Connective tissue sheath
h
A. .
I,If
4p
S
4 ea r
ntenor wad
Cross sectionthrough trachea
Posterior wallrf I
r4
',
r
I
Cartilage
Elastic fibers
Gland
Nerve
Small arteriesGland
Elastic fibers
Small artery
hYmlah vessels
Nerve
Epithelium
Trachealis muscle
Esophageal muscleEpithelium
Lymph vessels
r`
Toupperlobe
Intrapulmonary
i
A segment is not a functionalbecause it is not isolated by connective tissue .Neighboring segments share common venous andlymphatic drainage, and by collateral ventilationair asses across se nxental boundaries . The pleuraisolates one lobe from anothar, but since the mainor oblique fissure is complete in only about 50 % ofsubjects, even a lobe is not always unit .s an e
For countin r orders or enerations of airwa s itis sometimes apProPriate to count the trachea as thefrst eneration the main ronchi as the secondgeneration . and so on. To cornPare features within ase ment it is better to count the semancal bron-chi as the first eneration .
Tolingula
end unit
Top Related