KennedyJW(2012).ClinicalAnatomySeriesLowerRespiratoryTractAnatomy.

ScottishUniversities
MedicalJournal.1(2).p.174179

ClinicalAnatomySeriesLowerRespiratoryTractAnatomy

JohnW.Kennedy[5thyearMBChB,BMSc]
Correspondenceto:JohnKennedy:J.Y.Kennedy@dundee.ac.uk

ABSTRACT
Asdiscussedinthepreviousarticleofthisseries,1thenecessityforagreaterunderstanding
of anatomy has never been more pertinent.2,3 This paper continues on from the cardiac
anatomycoveredinthelastissuebystayinginthethoraxasthelowerrespiratorytractis
reviewedandplacedinaclinicalcontextrelevanttoundergraduatesandjuniordoctors.

ChestWallandDiaphragm
Itisdifficulttodiscusstheanatomyoftherespiratorysystemwithoutfirstconsideringthe
chest wall and diaphragm, given the crucial role of these structures in respiration. The
thoracic wall consists of skeletal and muscular components, extending between rib 1
superiorlyandrib12,thecostalmarginandthexiphoidprocessinferiorly.Thereare12ribs;
seventrueribsthatarticulatewiththesternumviacostalcartilageandfivefalsewhichdo
no not connect anteriorly. On the inferior aspect of each rib is a subcostal grove which
containsanerve,arteryandveini.e.aneurovascularbundle.4

Between the ribs are the intercostal muscles that and allowing for alterations in thoracic
volumes. These consist of three layers the external, internal and innermost intercostal
muscles.Theexternallayeraidsinspiration,whilsttheinternalandinnermostcontributesto
expiration.4

Thediaphragmisathinmuscularsheetthatdefinesthelowerlimitofthethorax.Itgains
attachment at the xiphisternum, costal margin and upper lumbar vertebrae. Multiple
structures pass through it, including (from anterior to posterior) the inferior vena cava,
oesophagus, aorta, azygous vein and thoracic duct. It is innervated by the phrenic nerve
(anterior rami of cervical spinal nerves 3, 4 and 5). Arising in the neck, the left and right
phrenic nerves pass over anterior scalene muscles deep to the carotid sheath, enter the
thoraxposteriortothebrachiocephalicveinsanddescendovertheheartwithinthefibrous
pericardium before piercing the diaphragm. Upon contraction, the diaphragm flattens to
increase the volume within the thorax and allow for inspiration. In addition,
sternocleidomastoid and the scalene muscles of the neck act as accessory muscles of
respiration,whichareutilisedtypicallyduringrespiratorydistress.4

Clinicalrelevance
Chest drain insertion is a commonly performed procedure in the management of pleural
effusion,pneumothoraxandempyema.Todoso,achesttubeisinsertedtypicallyatthe4th
or 5th intercostal space in the midaxillary line and passes through the intercostal muscles
andparietalpleuraintothepleuralspace.Duringthisprocedureitisimportanttodirectthe
incisionanddraintothesuperioraspectoftherib(e.g.inciseoversuperiorborderof6thrib
when passing through 5th intercostal space) otherwise damage can occur to the
neurovascularbundlelyingintheinferiorlylocatedsubcostalgroove.5Importantly,thiscan
produceahaemothoraxduetovesselinjury.6

As mentioned, both the intercostal muscles and diaphragm are vital for respiration.
Therefore,anyimpairmentoftheirfunctioncanbelifethreatening.Theintercostalmuscles
are innervated by intercostal nerves T1 T114 and as such, a cervical spinal cord lesion
KennedyJW(2012).ClinicalAnatomySeriesLowerRespiratoryTractAnatomy.ScottishUniversities
MedicalJournal.1(2).p.174179

would be required to affect all nerve roots. However, in conditions such as GuillianBarr
syndrome,myastheniagravisandmotorneuronedisease,whereweaknessandparalysiscan
occur in multiple areas, there can be a significant reduction in respiratory function,
potentiallyleadingtotype2respiratoryfailure(i.e.lowpO2andhighpCO2).7Giventhelong
routeofthephrenicnervefromC35intheneck,itcanbedamagedatmanypointsalongits
course to the diaphragm. Common causes of injury include cervical trauma (such as
vertebralfracture8andduringforcepsdeliveryofthenewborn9),andmalignancyintheneck
andthorax,10particularlywherethenerveliesanteriortothelunghilum.4

PleuralCavities
The lungs lie within the pleural cavities. Each cavity, found lateral to the mediastinum, is
lined by pleura a layer composed of mesothelial cells and connective tissue. The pleura
aresubdividedintoparietalandvisceralcomponents;theparietaladherestothechestwall
whilethevisceralcoversthelungs,witharelativevacuumbetweenthe2layersknownas
thepleuralcavityorspace.Asmallvolumeofpleuralfluidispresentinthispotentialspace
between the two layers that acts to lubricate movement between the pleura during
respiration. Inferiorly, below the lung bases, spaces exist between the parietal pleura
adherent to the chest wall and diaphragm, known as the costodiaphragmatic recesses.
Theserecessesexpandduringexpirationasthelungbasesmovesuperiorly.4

ClinicalRelevance
In the pleural space, there is the potential for excess air (pneumothorax) or fluid (pleural
effusion)toaccumulate.Thecausesforapleuraleffusiontodeveloparemultiple,andthe
compositionoftheeffusioncanbesplitintotransudatesandexudates,reflectingdifferent
aetiologies(Table1).Transudateshavealowproteinlevel(<25g/L)andgenerallyarisedue
to increased venous pressure or hypoproteinaemia. For example, an increase in left
ventriculardiastolicpressureoccursinleftsidedheartfailure,producingariseinpressure
within the pulmonary veins and capillaries.7 In contrast, exudates exhibit a high protein
level(>35g/L)andoccurasaresultofincreasedcapillarypermeability,typicallysecondaryto
infection,inflammationormalignancy.11

Table1:examplesofcausesfortransudatesandexudates
Transudates Exudates
Heartfailure Malignancy
Livercirrhosis Pulmonaryembolism
Nephroticsyndrome Pancreatitis
Myxoedema Rheumatoidarthritis
Lungs
Each lung originates from the central hilum that contains a number of key structures
including the pulmonary artery, two pulmonary veins, a main bronchus, bronchial vessels,
nervesandlymphatics.4

The right lung is composed of three lobes that are diveded by an oblique and horizontal
fissure. The oblique fissure runs between the lower and middle lobe, and the horizontal
fissurerunsbetweenthemiddleandupperlobe.Anumberofstructuresareadjacenttothe
rightlung,andindeedleaveimpressionsuponitsmedialsurface.Theseincludetheheart,
inferiorandsuperiorvenaecavae,azygosveinandoesophagus.4

Theleftlungisslightlysmallerthantherightduetothepredominantlyleftsidedpositionof
the mediastinum, and is split into an upper and lower lobe by the oblique fissure.
Additionally, a tonguelike projection, called the lingula, extends from the upper lobe over
KennedyJW(2012).ClinicalAnatomySeriesLowerRespiratoryTractAnatomy.ScottishUniversities
MedicalJournal.1(2).p.174179

theheartanteriorly.Keystructureswhichlieincloseapproximationtothemedialaspectof
theleftlungaretheheart,aorticarch,thoracicaortaandtheoesophagus.4

ClinicalRelevance
When auscultating the chest, it is important to appreciate the surface landmarks of each
lobe.Thisaidsdeterminingwhichlobeisaffectedbydisease.Ontheright,thefissuresare
demarcatedasfollows:

*Horizontalfissurefollowsthe4thintercostalspace
* Oblique fissure follows a curved line from the T2 spinous process posteriorly to rib 6
anteriorly4

Theupperlobeisthereforeauscultatedsuperiortothe4thintercostalspace,themiddlelobe
betweenthe4thintercostalspaceand6thribanteriorly,andthelowerlobeinferiortotheT2
spinousprocessposteriorly.

For the left lung the oblique fissure follows a curved line from the T2 spinous process
posteriorly to the costal cartilage of rib 6 anteriorly4 The left upper lobe is therefore
auscultated superior to T2 spinous process posteriorly and rib 6 anteriorly, and the lower
lobeinferiortothesepoints.Inaddition,thelungapicesshouldbeauscultated bilaterally
abovetheclavicles.12

As noted, several important structures lie in close proximity to the medial aspects of the
lungs.Therefore,anymassarisinginthisareacanquicklyinvolveanumberofsurrounding
structures,andthiswillclearlyaffecttheclinicalpicture.Examplesofstructuresthatmaybe
affectedandresultingsymptomsarepresentedinTable2.

Table2:structuresincloseproximitytothelungs,andsymptomsarisingfromtheir
dysfunction7
Anatomicalstructureaffected Symptom
Leftrecurrentlaryngealnerve Hoarseness
Phrenicnerve Dyspnoea
Sympatheticplexus HornersSyndrome(miosis,ptosis,anhidrosis)
Oesophagus Dysphagia,postprandialcoughing
Pericardium Palpitations
Pleura Chestpain,cough
Superiorvenacava Dilatedneckveins,plethora,dyspnoea

BronchialTree
The bronchial tree begins superiorly with the trachea, which is composed of C shaped
cartilageringswithanopenposteriorwallcomposedofsmoothmuscle.Thisbifurcatesinto
theleftandmainbronchiatvertebrallevelT4/5.Thisisalsothelevelofthesternomanubrial
joint(i.e.thesternalangle),thepulmonarytrunk,thebeginningandendoftheaorticarch,
and the entry point of the superior vena cava into the right atrium. The right bronchus is
bothmoreverticalandwiderthantheleft.Thesetwomainbronchithensplitintolobaror
secondarybronchithatsupplyalobeeach,andthenfurtherdivideintosegmentalortertiary
bronchi to supply one of 10 bronchopulmonary segments in each lung. These
bronchopulmonarysegmentsarediscretefunctionallyindependentsectionsoflungthatcan
be removed surgically without affecting adjacent segments. Further subdivisions occur
beforereachingthelevelofthebronchioles,theluminaeofwhicharenolongermaintained
bycartilage.4
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MedicalJournal.1(2).p.174179

Clinicalrelevance
Giventhemoreverticalcourseoftherightbronchusanditswiderlumen,aspirationmore
commonly affects the right lung.13 Furthermore, the right bronchus first divides into an
upper lobe bronchus and the bronchus intermedius. The bronchus intermedius continues
for around 5cm before dividing into the middle and lower lobe bronchi, and therefore
foreign material or masses which block this bronchus will collapse both the lower and
middlelobes.14

As mentioned, the bronchioles are not maintained by cartilage. They do contain smooth
muscle,however,andassuchcanconstrict(i.e.bronchoconstriction)whenstimulatedtodo
so.Thismechanismofsmallairwayconstrictionformsthebasisofasthma.7

PulmonaryVasculature
Arteries
Thepulmonaryarteriesarisefromthepulmonarytrunkandtransportdeoxygenatedblood
fromtherightventricletothelungs.Therightarteryislongerthantheleft,howeverboth
pass through the hilum of their respective lung and branch into lobar, segmental and
subsegmentalarteriesbeforeterminatingascapillarieswhichlinethewallsofthealveoli.14

The bronchial arteries branch from the thoracic aorta and posterior intercostal arteries to
supply the lung tissue and pleura. The vessels, carrying oxygenated blood, create an
anastomoticnetworkwiththepulmonaryarteriesandveins.4

Veins
Thepulmonaryveinsoriginateatthelunghilumasasuperiorandinferiorvein.Thesecarry
oxygenated blood from the lungs to the left atrium. Some bronchial veins also join with
thesepulmonaryvessels.4

Lymphaticdrainage
The principle route of lymphatic drainage for the body is through the thoracic duct. This
extendsfromvertebrallevelL2totherootoftheneck.Itbeginssuperiortotheconfluence
ofseverallymphducts,knownasthecisternachyli,whichdrainstheabdomen,pelvisand
lower limbs. The thoracic duct enters the thorax posterior to the aorta through the
diaphragm,andtraversessuperiorlythroughtheposteriormediastinumtotherightofthe
midline. It then moves to the left in the superior mediastinum, lying posterior to the
oesophagus, before entering the neck where it is joined by the left jugular and subclavian
trunksthatdrainthelefthead,neckandupperlimb.Thethoracicductthenemptiesintothe
venouscirculationatthejunctionbetweentheleftsubclavianandinternaljugularveins.4A
large palpable node in the supraclavicular area where the thoracic duct empties into the
venous circulation is known as Virchows node, and classically indicates abdominal
malignancy.7Lymphaticdrainagefromtherightsideofthehead,neckandupperlimbenters
circulation via the right jugular and subclavian trunks at the junction between the right
subclavianandinternaljugularveins.4

Clinicalrelevance
Pulmonary embolus (PE) is a common and potentially fatal condition. However, the
diagnosisisoftendelayedduetononspecificsymptomsandsignswhichnaturallyworsens
prognosis.15AsrepresentedinVirchowstriad,predisposingfactorstoPEincludeendothelial
injury,stasisorturbulentbloodflow,andhypercoagulablestates.10

KennedyJW(2012).ClinicalAnatomySeriesLowerRespiratoryTractAnatomy.ScottishUniversities
MedicalJournal.1(2).p.174179

Examplesofaetiologicalfactorsinclude16:

Venousstasis:immobilisation,polycythaemia,dehydration
Hypercoagulability:surgery,antithrombinIIIdeficiency,proteinS&Cdeficiency
Surgeryandtrauma:particularlyorthopaedicandspinalsurgery
Pregnancy
Malignancy:particularlypancreaticandbronchopulmonarytumours
Acutemedicalillness:e.g.inflammatoryboweldisease,MI,heartfailure16

Embolioftenarisefromthedeepveinsofthelowerlimb(i.e.DVT),suchasthepoplitealand
femoral veins, but not exclusively as the upper limbs and right side of the heart represent
otherpotentialsitesofthrombusformation.Thediameterofthepulmonaryarterylumen
thatisoccludedwilldeterminetheclinicalpicture,hencethevariabilityofpresentation,and
this is in part related to emboli size. The embolism can be characterised as central or
peripheral depending on the site of occlusion; central refers to the pulmonary trunk,
pulmonary arteries and lobar arteries, whereas peripheral indicates segmental and
subsegmentalarteries.17

Occlusion of a pulmonary arterial vessel results in increased alveolar dead space with
subsequenthypoxaemia,andanelevatedpulmonaryarterialpressurethatreducescardiac
output due to increased right ventricular afterload. Common symptoms and signs which
patients may present with are described in Table 3. Note that small/medium embolism
refers to peripheral vessel occlusion whilst a massive embolism involves occlusion of
central arteries. A further subdivision is chronic PE, where patients experience dyspnoea,
syncopeonexertion,andweaknessoverweeksandmonths.Again,itisimportanttonote
thevariabilitywithwhichpatientspresent,andnotallsymptomsandsignsarelikelytobe
evident.10ThemodifiedWellsscorecanbeusedtocalculatethelikelihoodofPE.18

The diagnosis of PE is primarily made with radiological investigations, however attention

shouldbepaidtothearterialbloodgas(typeIrespiratoryfailureifsignificantembolism),D
dimer(excludesPEifundetectable)andtheECG(mayshowevidenceofrightheartstrain:
e.g. right axis deviation, right bundle branch block and T wave inversion, however the
classicalpatternofS1,Q3,T3isrelativelyrare).10IfaPEissuspected,achestXray(CXR)
should first be performed. This may show linear atelectasis or a small pleural effusion,
however these are not diagnostic. However, the importance of performing the CXR is to
determine which investigation to request next: if the CXR is normal, a V/Q scan should be
performed but if any abnormalities are identified on the CXR, a CT pulmonary angiogram
shouldbecarriedoutinstead.19However,itshouldbenotedthatlessandlesscentresare
performingV/QperfusionscansastheavailabilityofCTpulmonaryangiogramsisimproving.

Table3:commonsymptomsandsignsfoundinsmall/mediumandmassivePE10
Small/mediumPE MassivePE
Pleuriticchestpain Severecentralchestpain
Dyspnoea Paleandsweaty
Haemoptysis Syncope
Tachypnoea Tachypnoea
Localiasedpleuralrub Tachycardia
NormalCVSexamination Hypotension
ElevatedJVP
Death

KennedyJW(2012).ClinicalAnatomySeriesLowerRespiratoryTractAnatomy.ScottishUniversities
MedicalJournal.1(2).p.174179

TreatmentofPEinvolveslowmolecularweightheparin(weightdependentdose)foratleast
fivedays,inadditiontohighflowO2andanalgesia.Treatmentwithheparinshouldnotbe
delayeduntilafterdiagnosticimaginginpatientswithahighsuspicionofPE.Inpregnancy,
different treatment regimes exist, which should be consulted. If there is significant
cardiovascular compromise thrombolysis with a recombinant tissue plasminogen activator,
such as alteplase, should be considered (in the absence of contraindications) and urgent
senioradvicesought.19Itisimportanttoreviewlocalguidelinesrelatingtothediagnosisand
managementofPE,however,tooptimisethedeliveryofcare.

FurtherReading
1ParkinI,LoganBM,McCarthyM.CoreAnatomyIllustrated.London:HodderArnold,2007
2 Ellis H. Clinical Anatomy: Applied Anatomy for Students and Junior Doctors. London: Wiley
Blackwell,London,2010

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