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