PTR3011

PULMONARY DISEASES AND REHABILITATION

2023-2024

Assist. Prof. Baha Naci

19.10.2023
5. Trachea

o Trachea has the shape of a fibrocartilage tube supported by 15-20 C-shaped cartilaginous
rings.

o It ends where it divides into the right and left main bronchi (bifurcatio trachea). This level is
the angulus sterni or T4-T5 intervertebral disc level.

o n. laryngealis recurrens, located between trachea and esophagus, sends branches to both
the esophagus and trachea.
Moore KL, Dalley AF, Agur AMR. (2010). Clinically Oriented Anatomy. (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
 6. Bronchi

o The main (primary) bronchus originates from the tracheal bifurcation at the level of the sternal
angle and proceeds inferolaterally to the lung hilus (pleural hilus).

o The right main bronchus is wider, shorter and more vertical than the left. It passes directly into
the hilus of the lung.

o The main bronchus enters the lung hilus and branches out into lobar (secondary) bronchi,
forming the bronchial tree. 2 lobar bronchi on the left and 3 on the right, each going to one lobe
of the lung.
o Each lobar bronchus divides into numerous segmental (tertiary) bronchi. Each
bronchopulmonary segment is surrounded by connective tissue which is an extension of the
visceral pleura.

o The bronchopulmonary segment is the largest subunit of the lobe. Each segment has its own
segmental bronchus, artery, autonomic nerves and vein. It is named according to the segmental
bronchus ventilating itself. They can be removed surgically.
o The bronchial tree divides dichotomously into two, starting from the trachea, and makes
an average of 23 branches.

o As the tracheobronchial tree branches and approaches the alveoli, the structure of its wall
changes. Although the walls of the trachea, main bronchi and lobar bronchi are kept open
by cartilage rings, the cartilage rings in the walls of the segmental bronchi become more
rare cartilage islands. As the bronchus branches out and becomes thinner, the cartilage
islands also become rare and the cartilage begins to be replaced by active smooth muscle
tissue.

o At the distal end of the terminal bronchioles, the cartilage completely disappears, leaving
only smooth muscle tissue in the wall. Cilia and mucus-producing cells also disappear.
Terminal bronchioles are the most terminal airways that do not have alveolar structures in
their walls and their diameter is 0.5 mm.
o Respiratory bronchioles are formed by several divisions of each terminal bronchiole. Each
respiratory bronchiole gives rise to alveolar sacs lined with alveoli, which are the primary units
of gas exchange.

o The walls of the alveolar canals consist entirely of alveoli. They are the most terminal airways
with smooth muscles in their walls. The alveolar sac is the 23rd branching of the air passage
and contains approximately 17 alveoli each.

o Alveoli begin to appear on the first row respiratory bronchiole, which determines the
beginning of the respiratory part of the lung. Alveoli are initially single, then appear in larger
numbers and come together in sacs. Each sac has an empty space in the middle called the
ductus alveolaris, which continues with the lumen of the respiratory bronchiole. The surface
of the alveolar canals are completely covered with alveoli.
 Structure of the Bronchial Tree

o C-shaped cartilages in the trachea take the shape of a ring in the intrapulmonary sections of
the main bronchi and around the lower lobe bronchi.

o The bronchi are lined with ciliated columnar epithelium. Under the lamina propria, there are
abundant submucosal secretory glands and Goblet cells. Goblet cells are found in the
trachea, bronchi, and large bronchioles and, together with the submucosal glands, they
secrete high molecular weight mucus glycoprotein.

o Secretory Goblet cells, located in the respiratory tract mucosa starting from the
nasopharynx, gradually decrease, and disappear from the small bronchioles.

o While the large bronchioles are covered with ciliated columnar epithelium, the small
bronchioles are covered with non-ciliated cuboidal epithelial cells.
 Alveolar structure

o Alveolar epithelium consists of two cell types. Type I squamous epithelial cells (squamous
pneumocytes) cover 95% of the alveolar surface.

o Type II epithelial cells (granular pneumocytes), located in the corners of the alveoli, are
cuboid-shaped, larger and more numerous, and cover 5% of the alveolar surface. They are
responsible for the production of "surfactant" in phospholipid structure and are located
towards the alveolar air spaces. Surfactant substances are found on the surface of the
alveolar epithelium, and they prevent small-sized alveoli from atelectasis by reducing the
surface tension as the alveoli collapse. Surfactant also prevents fluid leakage from the
interstitium into the alveoli.

o Connective tissue with abundant elastic fibers has entered between the branches of the
bronchial tree and the alveoli. These elastic fibers store energy when stretched during
inspiration and enable the elastic recoil mechanism of the lung to occur during expiration.
o Ventilation of the alveoli can also be provided by collateral pathways
other than bronchioles. Gas passage between adjacent alveoli is
provided by the Pores of Kohn (alveolar pores). Their diameters expand
during inspiration, and they play a role in balancing the pressure
between neighboring alveoli. They facilitate the spread of infection due
to bacterial transmission during pneumonia.

o In the lungs, there are also Canals of Lambert between the terminal
bronchioles and the alveoli in the adjacent acini. Especially in COPD,
despite small expiratory airway collapse, alveolar collapse is prevented
by the collateral ventilation provided by these pores and canals.

o Among the bronchiolar epithelial cells are the mitochondria-rich,

cuboid-shaped Clara cells, also known as nonciliary, nonmucous
secretory cells. They are protein secretory cells and play a role in the
regulation of pulmonary homeostasis in inflammatory conditions.
o The tracheobronchial tree is functionally divided into the conducting zone and the
respiratory zone. The part of the lower respiratory tract, including the terminal bronchioles,
ensures the conduction of respiratory air and is called the conductive zone. This area where
there is no gas exchange is defined as anatomic dead space.

o Respiratory bronchioles, alveolar ducts, alveolar sacs and alveoli located distal to a terminal
bronchiole form terminal respiratory units called "acinus". In other words, the acinus,
which is the lung unit ventilated by a single terminal bronchiole, both transmits air, and
provides gas exchange with the alveolar structure on its walls. Therefore, the airways distal
to the terminal bronchioles are called the respiratory zone.

o In the bronchial tree, a group of three to five acini with terminal bronchioles projecting
from each other form a lobulus pulmonalis, the smallest, morphologically distinct structural
unit of the lung.
https://en.wikipedia.org/wiki/Respiratory_tract https://www.researchgate.net/figure/The-conductive-and-respiratory-
zones-of-the-lungs-12-Inhalation-antibiotic-therapy_fig1_50998834
o Bronchopulmonary segments divide further to form pulmonary lobules.

o Pulmonary lobules consist of pulmonary acini.

o Each acinus consists of respiratory bronchioles and alveoli.

o The conductive airways receive arterial blood from the bronchial circulation (descending
aortic branches), while respiratory zone receives arterial blood from the pulmonary
arteries.
 7. Lungs

o Located on both sides of the anatomical space called mediastinum within the rib cage. They are
connected to the mediastinal structures via the hilus.

o The lungs are completely surrounded by visceral pleura, except for the hilum pulmonis, and each of
them is located freely within a pleural cavity. They contain apex, basis, three edges and two faces.

o There are three lobes in the right lung separated by oblique and horizontal fissures, and two lobes in
the left lung separated by oblique fissure. On the right, the horizontal fissure separates the upper lobe
from the middle lobe, and the oblique fissure separates the upper and middle lobes from the lower
lobe.

o The lingula, which is corresponding the middle lobe in the left lung, belongs to the upper lobe. The
right lung is larger and heavier.

o Incisura cardiaca indents primarily on the anteroinferior surface of the upper lobe of the left lung. This
often forms a thin, tongue-like projection (lingula) on the superior lobe.
Apex Pulmonis: It rises 3–4 cm above the 1st costal cartilage, towards the root of the neck. The
pleura cervicalis covers this part like a tent. Neighborhoods of the apex are through the pleura.
In lung auscultation, the apex should also be listened with a stethoscope above the inner 1/3
of the clavicle. In penetrating injuries to the cupula pleura, the lung apex may also be
damaged.

o Costal face; It is large, flat and convex. It is adjacent to the costal pleura, and the pleura
separates it from the ribs, rib fractures and mm.intercostales intimi. Its posterior part is
associated with the bodies of the thoracic vertebrae.
o Mediastinal face; It is concave because it is adjacent to the middle mediastinum, where the
pericardium and heart are located. It contains the hilum, so it includes the lung roots and
forms a pleural cover around it.
o Diaphragmatic face; It is concave and forms the lung base that sits on the base of the
diaphragm.
o Anterior edge; where the costal and mediastinal aspects meet anteriorly and overlap the
heart; incisura cardiaca indents this edge of the left lung.

o Inferior edge; It surrounds the diaphragmatic aspect of the lung and separates it from the
costal and mediastinal aspects.

o Posterior edge; where the costal and mediastinal surfaces meet posteriorly; It is wide and
round.
Frank H. Netter (çeviri editörü Meserret Cumhur). Netter İnsan Anatomisi Atlası, 6. baskı. Nobel Tıp Kitabevi, 2015.
 Pleura

o The pleura is a two-layered serous membrane that covers the lungs and the inner surface of
the chest wall, facilitating the movement of the lungs within the thorax during respiration.

o The visceral pleura covers the entire outer surface of the lungs and the interlobar fissures,
fusing with the parietal pleura at the hilus.

o The parietal pleura covers the inner surfaces of the ribs and intercostal muscles as well as
the lateral surfaces of the mediastinum and most of the upper surface of the diaphragm.
Both pleural leaves are in contact with each other in many regions during inspiration.

o Visceral and parietal pleura leaves join each other at the hilus.
1. Visceral pleura; tightly surrounds the lung and adheres to its all surfaces. It provides a smooth
and slippery surface to the lung, allowing it to move easily over the parietal pleura.
2. Parietal pleura; lines the pulmonary cavity and attaches to the thoracic wall, mediastinum, and
diaphragm. It consists of 4 parts.

o Costal pleura covers the inner surface of the thorax wall.

o Mediastinal pleura covers the lateral aspects of the mediastinum. It passes to the outer side at
the hilum and surrounds the structures within the root and continues as a double layer by fusing
with the visceral pleura. This part is called lig. pulmonale. Anteriorly, the costal pleura curves
sharply into the mediastinum and continues with the mediastinal pleura. This folding edge is
called the anterior edge of the pleura. The space between the pleura leaves in this folding edge
is called recessus costomediastinalis.
o Diaphragmatic pleura covers the superior and thoracic surfaces of the diaphragm on both
sides of the mediastinum. Around the diaphragm, at the transition edges where the
diaphragmatic pleura jumps to the thorax wall and becomes the costal pleura, the pleural
cavity forms a sharp circular dead-end. This dead-end is called recessus
costodiaphragmaticus. During deep inspiration, the lower borders of the lung moves
deeper into the pleural recesses and retract during expiration.

o Cervical pleura (pleural dome) extends from the upper thoracic aperture to the root of the
neck. It forms the pleural dome at the apex of the lung. Its peak is 2-3 cm above the medial
1/3 of the clavicle, at the level of the first rib neck.
Frank H. Netter (çeviri editörü Meserret Cumhur). Netter İnsan Anatomisi Atlası, 6. baskı. Nobel Tıp Kitabevi, 2015.
 Vessels of the Lung

• a. pulmonalis; brings venous blood to the lungs. Together with the segmental bronchi, it
supplies the lung segmentally.
• Bronchial artery; nourishes bronchi, bronchioles, the walls of intrapulmonary arteries and
veins. Two a. bronchialis sinister arise from aorta thoracica, one a. bronchialis dexter arises
from the first intercostal artery.

v. pulmonalis superior dexter: drains upper and middle lobe of the right lung
v. pulm. superior sinister: drains upper lobe of the left lung
v. pulm. inferiores: drain the lower lobes of the lungs.

Vv. Bronchiales; start from the large branches of the bronchi and drain the larger subgroups of
the bronchi. Right bronchial vein drains into v. azygos, while left bronchial vein drains into v.
hemiazygos accessorius.
Frank H. Netter (çeviri editörü Meserret Cumhur). Netter İnsan Anatomisi Atlası, 6. baskı. Nobel Tıp Kitabevi, 2015.
 Innervation of the Lungs and the
Pleura

• Parasympathetics emerge from the vagus (vasodilator, bronchoconstrictor, secretomotor).

Sympathetic nerve fibers emerge from T1-T5 segments. It settles in the lungs through the
plexus cardiacus and plexus pulmonalis. They act as vasoconstrictor, bronchodilator and
secretoinhibitor.

• The nerves of the visceral pleura emerge from the plexus pulmonalis. There is no pain
sensation in the visceral pleura. The parietal pleura (especially the costal part) is extremely
sensitive to pain. Irritation of the costal and peripheral diaphragmatic areas causes pain.
This pain can be felt in the thorax wall, abdominal wall, lower neck and shoulder.
 Lines on the Thorax Wall

• Anterior median line (midsternal); intersection of median wall and anterior chest wall
• Midclavicular line; passes from the midpoint of the clavicles parallel to the anterior median
line.
• Anterior axillary line; extends vertically along the anterior axillary fold by forming the
border of m. pectoralis major.
• Mid-axillary line; extends from the apex of the axilla parallel to the anterior axillary line.
• Posterior axillary line; extends vertically along the posterior axillary fold formed by the
latissimus dorsi and teres major muscles.
• Scapular line; the line passing from the inferior part of the angulus scapula parallel to the
posterior median line.
 Superficial Anatomy of Pleura and Lungs

• The apex of the lungs extends approximately 2-3 cm above the medial 1/3 of the clavicle.

• Pleural reflections reach the midclavicular line at the level of the 8th costal cartilage, the
10th rib at the midaxillary line, and the 12th rib at the scapular line.

• The lower borders of the lungs reach the midclavicular line at the 6th rib, the midaxillary line
at the 8th rib, and the scapular line at the 10th rib, progressing towards the T10 processus
spinosus.

• The oblique fissure of the lungs extends from the T2 spinous process level (3rd
costovertebral joint) posteriorly to the 6th costal cartilage anteriorly. The horizontal fissure
of the right lung extends along the 4th rib from the oblique fissure to the costal cartilage
anteriorly.
 Mediastinum

• The area between the two pleural sacs is called mediastinum. Borders:
• Superior: Apertura thoracis superior; Inferior: Diaphragm; Anterior: Sternum and
costal cartilages; Posterior: Corpus vertebra thoracicae

• Mediastinum superius is on the line passing through the angulus sterni anteriorly and
the T4-5 intervertebral disc posteriorly. This are includes thymus, great cardiac vessels,
n. vagus, n. phrenicus, n. laryngeus recurrens, ductus thoracicus, trachea, esophagus.

• Mediastinum inferius extends from the border of the upper mediastinum to the
diaphragm and is divided by the pericardium into anterior, middle and posterior parts.
Mediastinum medium contains the pericardium, heart and great vessels. Medistenum
anterius is the smallest compartment. The mediastenum posterius is behind the
pericardium and diaphragm, including esophagus, thoracic sympathetic trunk, ductus
thoracicus, v. azygos, v. hemiazygos and thoracic aorta.
 REFERENCES

1. Moore KL, Dalley AF. (1999). Clinically Oriented Anatomy. (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
2. Tamer AŞ, Kılıçaslan Z., editörler. (2015). Solunum Dilimi-1 Ders Notları. Nobel Tıp Kitabevleri.
3. Moore KL, Dalley AF, Agur AMR. (2010). Clinically Oriented Anatomy. (6th ed.). Philadelphia: Lippincott Williams &
Wilkins.
4. Uzun M, editör. (2014). Kardiyak ve Pulmoner Rehabilitasyon. İstanbul Tıp Kitabevi
5. Harutoğlu H, editör. (2019). Pulmoner Rehabilitasyon. Hipokrat Kitabevi
6. Perry M, Whyte A. Immunology of the tonsils. Immunology Today 1998;19(9):1-2 Şeftalioğlu A. “Tonsillerin
gelişmesi”, Tonsil, Kaya S (Ed), Bilimsel Tıp Yayınevi, Ankara; 2005, s. 8-13.
7. Perry M, Whyte A. Immunology of the tonsils. Immunology Today 1998;19(9):1-2 Şeftalioğlu A. “Tonsillerin
gelişmesi”, Tonsil, Kaya S (Ed), Bilimsel Tıp Yayınevi, Ankara; 2005, s. 8-13.
8. Hillegass E. (2017). Essentials of Cardiopulmonary Physical Therapy. (4th ed.). Missouri: Elsevier.
9. Durgun B., Gilroy Anatomi Atlası (Atlas of Anatomy, Gilroy, A.M., MacPherson B.R, Ross, L.M.) Çeviri Editörleri:
H.Hamdi Çelik, C. Cem Denk). Palme Yayıncılık Ankara, 673 s., 2010

THANK YOU…