TRACHEOBRONCHIAL

TREE &
BRONCHOPULMONAR
Y SEGMENTS
GUIDE: PRESENTOR:
Dr.Samuel George M.D, Dr.Sathya.T.V,
Assistant Professor, Post Graduate,
Department of Anaesthesia, Department of Anaesthesia,
GTMCH-Theni. GTMCH-Theni
TRACHEOBRONCHIAL TREE

■ Conduit for ventilation and clearance of

tracheal and bronchial secretions
■ 23 generations
■ ‘0’ generation – Trachea
‘23’ generation – Alveolar sac
■ Dichotomous division
DEVELOPMENT

■ Tracheobronchial groove appears in

early embryo
■ Median ventral diverticulum in
foregut
■ Separated from primitive oesophagus
except at laryngeal aditus
■ Caudal prolongation – 2 main bronchi
further proliferation – formation of
lung bud on each side

TRACHEO-OESOPHAGEAL FISTULA:
- Embryonic anomaly
- Atresia of esophagus with fistula
below atretic segment
TRACHEO-ESOPHAGEAL FISTULA
AIRWAY

AIRWAY COMPONENTS FUNCTIONS

CONDUCTIVE Trachea to Terminal Bulk gas movement

bronchioles

TRANSITIONAL 1)Respiratory bronchioles 1)Bulk gas movement

2)Alveolar ducts 2)Limited gas diffusion and
exchange

RESPIRATORY Alveolar sacs Gas exchange

Alveoli

Clinical anesthesia – 8th edition by Paul.G.Barash

TRACHEA
■ Fibromuscular tube
■ Extrathoracic(cervical) and intrathoracic

EXTENSION:
■ Lower end of cricoid cartilage(C6) to Termination of tracheal
bifurcation(T4/T5/T6)

DIMENSIONS:
■ Length - 15cm(5cm cervical)
■ Diameter - Diameter of person’s index finger
■ Diameter of ET tube(pediatric) – diameter of person’s lillte finger

COMPOSITION :
■ 16-20 U shaped cartilages or rings ,
vertically by fibroelastic tissue,
posteriorly by non-striated trachealis muscle
NARROW PARTS:

■ Cricoid cartilage(diameter – 17mm males,18mm females)

■ Carina
- tracheal bifurcation
- keel shaped cartilage
- little left to midline
- short, sharp, shining, sagittal ridge on Bronchoscopy
- Flattening
1)Enlargement of Hilar LN
2)Fibrosis/tumors/lung pathology
RELATIONS
CERVICAL TRACHEA:
■ Anterior
- Skin, Superficial and deep fascia,
- Isthmus of thyroid(2nd to 4th
tracheal rings)
- Sternohyoid, Sternothyroid muscles
- Superior Thyroid Artery, Thyroid
ima artery,
- Inferior thyroid Vein

IMPORTANCE:
Erosion of tracheal wall by Tracheostomy
tube can lead to sudden profuse
hemorrhage
■ Lateral :
- Lobes of thyroid
- Carotid sheath(CCA/ IJV/
Vagus)
- Sympathetic chain
■ Posterior :
- Oesophagus
- Recurrent Laryngeal nerve(RLN)

IMPORTANCE :
1)During oesophagoscopy , high pressure
cuffed ET tubes – Anterior wall
compression of oesophagus
2)Superficial – cuff with 5ml air felt by
placing 2 fingers over suprasternal
notch
THORACIC TRACHEA :

■ Anterior :
- Inferior Thyroid Artery
- Sternothyroid
- Remains of thymus
- Brachiocephalic Artery
■ Posterior :
- Oesophagus
- left RLN
■ Lateral :
Right side :- Azygos Vein and
Right Vagus nerve
Left side :- Left CCA, left
Subclavian Artery, Aortic Arch,
left vagus nerve,
RIGHT SIDE LEFT SIDE
■ INFANTS:
1)Thymus – large / lower part of cervical trachea
2)Brachiocephalic artery – crosses trachea behind suprasternal
notch
3)Left brachiocephalic vein – anterior relation of cervical trachea

IMPORTANCE:
Hemorrhage in asphyxiated child during tracheostomy

AWARENESS OF AIRWAY MOTION:

■ Adults – tip of orotracheal tube moves about 3.8cm(flexion &
extension of neck)
■ Infants & children – 1cm displacement can cause unintentional
extubation or bronchial intubation
■ Supplied by :
1) Inferior thyroid artery
2) Inferior thyroid vein
3) Deep cervical, pre and paratracheal LN
4) RLN , middle cervical ganglion
TRACHEOSTOMY
■ Position – head fully extended with sand bag under the
shoulders
■ Vertical incision from lower border of cricoid cartilage to
above suprasternal notch
■ Investing layer of fascia – split vertically
■ Pretracheal muscles separated
■ Isthmus pushed downwards or dissected and divided
■ Small vertical incision on trachea between 2nd and 3rd tracheal
rings
■ Tracheostomy tube of largest size inserted
■ Trachea aspirated
■ Closure – 2 or 3 skin sutures
TRACHEOSTOMY
PERCUTANOEOUS TRACHEOSTOMY

■ Position – supine ; fully extended neck

■ Ideal site – between 2nd and 3rd tracheal rings
■ Local anesthetic injected
■ 1cm incision over trachea
■ Needle with syringe inserted and aspiration of air confirms
position
■ Wire passed through it
■ Series of dilators passed through
■ Tracheostomy tube inserted
CRICOTHYROTOMY
CRICOTHYROID MEMBRANE :
■ Most superficial structure
■ Relatively avascular
■ 1-1.5 fingerbreadths(2-3cm) below
thyroid cartilage in the midline in adults
■ Infants & children – located by following
thyroid cartilage
■ Arteries & veins – upper third portion ,
lateral side
■ USG – hyperechoic band

TYPES :
1) Surgical cricothyrotomy – Standard &
Seldinger
2) Needle cricothyrotomy
STANDARD SURGICAL CRICOTHYROTOMY
■ Semi urgent scenarios
■ Position – hyperextension of neck
■ Disinfection and draping
■ Infiltration with 1% lignocaine
with adrenaline
■ Laryngeal handshake
■ Skin – vertical incision around
2cm
■ Membrane – horizontal incision
1cm in lower half
■ Insert Tracheal hook
■ Insert the dilator
Laryngeal handshake
■ Insert 6mm cuffed ET tube,
inflate ,cut to appropriate length
MODIFICATIONS:
1)Rapid four-step technique
2)Quick three step technique
SELDINGER TECHNIQUE
NEEDLE CRICOTHYROTOMY WITH PERCUTANEOUS
TRANS TRACHEAL VENTILATION
CONTRAINDICATIONS FOR NEEDLE TECHNIQUE:
■ Laryngeal injury
■ Tracheal rupture
■ Tracheal dissection

COMPLICATIONS OF CRICOTHYROTOMY:
■ Subcutaneous emphysema
■ Bleeding
■ Risk of aspiration
■ Inadequate ventilation
 POSTURAL DRAINAGE

■ AIM : to empty the pool

of lung secretions by
gravity assisted drainage
into larger airway, from
where it is coughed out
■ Done preoperatively to
improve postoperative
lung function
■ Different positions for
draining secretions from
different BPS
DIFFERENCE BETWEEN ADULT & PEDIATRIC AIRWAY

PROPERTIES ADULT PEDIATRIC

Head flat occiput Large prominent occiput

Tongue Relatively smaller Relatively larger

Larynx Opposite to C4-C6 Opposite to C3-C5

Epiglottis Flat ,flexible Soft, omega shaped

Vocal cords horizontal Short,concave

Smallest diameter glottis Sub glottis

cartilage Firm, calcified Soft, less calcified

Lower airway Larger, more developed Smaller, less developed

Alveoli 300-500million by 8-9yrs Fewer ,smaller

Cilia mature immature

Mucous cells normal more

Hyoid-thyroid apart Very close

separation
PROPERTIES ADULT PEDIATRIC

Lung volume 6000ml 250ml at birth

Respiratory rate normal increased

O2 consumption 3-4 mL/kg/min 6-8 mL/kg/min

 MAIN BRONCHUS (1st generation)

RIGHT MAIN BRONCHUS LEFT MAIN BRONCHUS

■ Shorter ■ Longer
■ Wider ■ Narrower
■ More vertical (25degrees to ■ Obliquely place (45degrees to
vertical plane) vertical plane)
■ Azygos vein arches over ■ Aortic arch arches over
■ Right pulmonary artery – below ■ Left pulmonary artery – above
and front and front
IMPORTANCE :
Inhaled FB or Bronchial aspirating
catheter enters
RIGHT UL BRONCHUS LEFT UL BRONCHUS

■ 2.5cm from carina ■ 5cm from carina

■ 10% - <2.5cm from carina
■ 2 to 3% - superior to carina
■ (Require special consideration
when placing double lumen
tubes)
■ Left sided endobronchial tubes
■ Right sided endobronchial tubes - no special arrangement
- orifice on the lateral surface
which coincides with the ■ Preferred – greater margin of
opening of right UL bronchus safety
■ (this avoids risk of obstruction ■ Position checked by fibreoptic
of right LL) bronchoscopy
ENDOBRONCHIAL TUBES

LEFT RIGHT
LOBAR BRONCHI(2nd, 3rd ,4th generation):
■ Total Cross sectional area - minimal at 3rd generation
■ Larger bronchi - affected by intrathoracic
pressure(>50cmH2O)

SMALL BRONCHI(5th – 11th generation):

■ Lie close to branches of pulmonary artery, in a sheath with
lymphatics
■ Imp: Pulmonary edema - distended with edema fluid
- cuffing (X-ray)
■ Rely on the cartilage for their patency.
BRONCHIOLES (12th – 14th generation):
■ Cartilages disappear
■ Thick muscle
■ Embedded in lung parenchyma
■ Calibre maintained by lung volume
■ Total cross sectional area increases until Terminal bronchioles
(100 times larger bronchi)
■ Each bronchiole with its subdivision – primary lung lobule
RESPIRATORY
BRONCHIOLES
(15th – 18th generation):
■ 0.4 mm diameter
■ Embedded in lung
parenchyma
■ Function - Bulky gas
movement
ALVEOLAR DUCTS (19th –
22nd generation):
■ Distal extremity of each
respiratory bronchiole
■ Wall – smooth muscle
■ 35% of alveolar gas resides
here
■ Gives rise to 3-6 spherical
chambers(atria)

ALVEOLAR SAC (23rd

generation):
■ Each sac – 17 alveoli
ALVEOLI(Air cells):
■ 0.2um thickness
■ No.of alveoli increases with age
Birth – 24 million
8 to 9 yrs – 300 to 500 million
■ Membrane Surface area 50-100m2

■ Wall – asymmetrically arranged

1)Thin side (0.4um)- gas
exchange(alveolocapillary membrane)
2)Thick side(1-2um)- fluid
exchange (pulmonary interstitial
space)
TYPE I
• 80% of alveolar surface
• Flattened squamous cells
• Thin cytoplasmic extension

CELLS • Highly susceptible to injury(ALI/ ARDS) – replaced

by Type II cells

• 10% of alveolar surface

TYPE II • Polygonal cells

• Enzymatic activity – 50% surfanctant production,

CELLS
50% modulates local
electrolyte balance, endothelial and lymphatic cell
function

TYPE III • <10% alveolar surface

• Alveolar macrophages

CELLS
• Immunological lung defence
• Controversial (beneficial Vs harmful)
SURFANCANT
■ Type II cells
■ Lipoprotein complex
■ Lipid - dipalmitoylphosphatidylcholine
■ Stored in Lamellar bodies
■ Decreases surface tension
■ Prevents the alveoli from collapsing
■ Begins – 2 to 3wks of IUL ; increases with maturity
■ Absence – RDS of newborn
■ Assessment – presence of lecithin in amniotic fluid
ANATOMICAL DIVISION
SUBSEGMENTS
■ 42 subsegments
■ 22 on Right lung, 20 on left lung
■ Predicted potopreative FEV1
calculated by counting the no. of
subsegments to be removed

■ PpoFEV1 % =
preoperative FEV1 % x [1 – (No.
of subsegments removed/42)]

■ If PpoFEV1 <40% of the

predicted normal value – high
risk of postoperative pulmonary
complications
WEST ZONES
 BRONCHOPULMONARY SEGMENTS

■ Functional division of lungs

■ Own bronchus/ own blood supply
from pulmonary A
■ Distinct from adjacent segments
■ 10 segments on either lung
■ IMPORTANCE
1)Lung resection surgery
2)Localizing lung pathology
3)postural drainage
4)chest radiodiagnosis
UPPER LOBE
1.Apical
2.Posterior
3.Anterior

MIDDLE LOBE LINGULA

4.Medial 4.superior
5.Lateral 5.inferior

LOWER LOBE LOWER

LOBE
6.Apical 6.Apical
7.Medial basal(cardiac)
8.Ant basal 8.Ant basal
9.Lat basal 9.Lat basal
10.Post basal 10.Post basal
LINGULA :
■ Leaf life structure
■ Anteroinferior part of left UL
■ Inferior or lingular division of Left UL bronchus , which
further divides into superior and inferior lingular branches
supplies this segment
■ Downwards/forwards/laterally
■ Affected together with left LL in infection of bronchiectasis

APICAL SEGMENT OF RIGHT LL :

■ Directed posteriorly from the stem of right LL bronchus
■ Inhaled body or secretions collect here
BRONCHOSCOPIC ANATOMY
■ Trachea – glistening tube, white at
rings, reddish in between
■ Left side – pulsation felt due to
aorta
■ Carina
■ Right side
1)UL bronchus – tricornate
appearance (lat wall)
2)ML bronchus – horizontal ridge
(ant wall)
3)LL bronchus – apical(post wall) ;
cardiac end (medial wall)
remaining 3 is clumped together
■ Left side
1)UL bronchus - 2 parts (lingular &
UL bronchus proper)
2)LL bronchus - apical (post wall)
remaining 3 is clumped together
STRUCTURE OF LUNG AND BRONCHIAL TREE
• Trachea, larger bronchi – ciliated columnar
epithelium

chronic inflammation/prolonged intubation –

squamous metaplasia
MUCOSA :
• Finer bronchi – ciliated cuboidal epithelium
• Alveoli – flattened cells with nuclei
• IMPORTANCE : high pressure ETT cuffs can
cause mucosal necrosis

BASEMENT MEMBRANE

• Elastic fibres(elastic recoil to conducting system)

SUBMUCOSA • Negative intrapleural pressure(decreases with age)
• Rich capillary vascular plexus and lymphatic tissue

NON-STRIATED BRONCHIAL • Increases as bronchi becomes narrow

MUSCLE: • Disappear beyond alveolar ducts

• Irregular cartilaginous plates

OUTER FIBROUS COAT: • Saddle shaped piece between 2 bronchial division
• Disappear in bronchioles of 0.6mm diameter
 BLOOD SUPPLY
PULMONARY ARTERY :
■ Below level of terminal bronchioles
■ Arises from right heart
■ Right and left (one for each lung)
■ Deoxygenated blood to lungs for gaseous exchange
■ Flow,pressure,resistance – 1/6th of systemic
circulation
■ Follows ramification of bronchial tree
PULMONARY CAPILLARIES :
■ Pulmonary capillary plexus –
close relationship with alveoli
■ Blood flow affected by alveolar
size and gravity
■ Upright –
apex ; large alveoli ,CSA
decreases, resistance increases,
decreased flow
base ; small alveoli , CSA
increases, resistance decreases,
increased flow
■ Resting – 75% filled
PULMONARY VEINS:
■ Tributaries – capillaries of pulmonary A and Bronchial A
■ Between lung segments
■ IMPORTANCE : Valuable landmark to surgeon during
segmental resections
■ At the apex of each BPS – pulmonary V draining that
segment rests; reaches hilum along with segmental
artery
■ 2 main pulmonary veins from each side
■ Right side - Right UL,ML & Right LL
■ Left side - Left UL & LL
BRONCHIAL ARTERY:
■ <4% of cardiac output
■ Left BA(2) – branch of descending thoracic aorta
■ Right BA(1) – variable origin
■ Supplies upto terminal bronchioles/ lung tissue/ visceral
pleura/ pulmonary nodes

BRONCHIAL VEIN :
■ Right – azygos vein
■ Left – superior hemiazygos vein (or) superior intercostal vein
LYMPHATICS
Superficial plexus -
visceral pleura
Deep plexus
- bronchi upto alveolar
ducts

Bronchopulmonary LN

Tracheobronchial LN

Bronchomediastinal
trunk

Right - Right lymphatic

duct Left -Thoracic
duct
NERVE SUPPLY:
■ SNS – T2 to T4
PNS – Vagus nerve

■ PNS – Bronchoconstrictor ;
increases bronchial
secretions(M receptors)

■ SNS - Bronchodilator ;
decreases bronchial
ᵦ
secretions( 2 receptors)

■ Afferent(stretch) fibres –
medullary respiratory
centre(vagus)
PHYSIOLOGICAL DEAD SPACE
■ Any part of tidal volume not participating in gaseous exchange
■ Physiological dead space= Anatomical dead space + Alveolar
dead space
■ Normal = 150ml + 0 = 150ml
ANATOMICAL DEAD SPACE:
■ Oronasophayrnx to respiratory bronchioles
■ 100-150ml
■ ⅓rd of tidal volume
■ Conditions modifying ANS
1)Tracheal intubation
2)Tracheostomy
3)Large lengths of ventilator tubing between tracheal tubes &
ventilator Y piece
■ Inspiratory and expiratory limb – unidirectional flow (not a
component)
ALVEOLAR DEAD SPACE:
• Ventilation of alveolus with inadequate or no perfusion
• PDS primarily affected by ALDS changes
• Conditions modifying ALDS :
1)Abrupt decrease in C.O(commonest)
2)Pulmonary embolism
3)Positive pressure ventilation or positive airway pressure
 REFERENCES

■ Anatomy for anaesthesists – 8th edition by Harold Ellis

■ Miller’s Anesthesia – 9th edition
■ Morgan & Mikhail’s clinical anesthesiology – 6th edition
■ Clinical anesthesia – 8th edition by Paul.G.Barash
■ Understanding anesthetic equipments & procedure – 2nd
edition by Dwarkadas K Baheti, Vandana V Laheri
 YOU
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