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Location : Thorax Neurovascular Bundle
Found between the middle and innermost muscles.

Lie in groove on inferior aspect of rib.
List neurovascular bundle structures from superior to inferior.
V - Vein
A - Artery
N - Nerve
Posterior Intercostal Artery : Spaces 1 and 2
Branches of Superior Intercostal Artery.
Which is a branch of Costo-cervical trunk of Subclavian Artery.
Posterior Intercostal Artery : Lower 9 Spaces
Branches of Descending Thoracic Aorta.
Each run from posterior to anterior in subcostal groove / inferior to vein)
Anterior Intercostal Arteries : Spaces 1 - 6.
Branches of Internal thoracic artery
Anterior Intercostal Arteries : Spaces 7 - 9.
From musculophrenic artery.
Where do the posterior and anterior artery terminate?
Common anastamose site joining the two.
Posterior Intercostal veins : Blood Flow.
Empty into either the azygos or hemiazygos veins.
Anterior Intercostal veins : Blood Flow.
Empty into internal thoracic and musculophrenic veins.
Intercostal Nerves
Anterior primary rami of thoracic nerves
Each give collateral muscular branch / lateral and anterior cutaneious branch to innervate thoracic and abd wall.
Diaphragm
Dome-shaped septum dividing the thoracic and abdominal cavities. (Thoracic Outlet)
Comprisesa periphreal muscular part and a central aponeurosis.
Aponeurosis
Flat sheet or ribbon of tendonlike material that anchors a muscle or connects it with the part that the muscle moves
List the 3 parts of diaphragm muscle fibers.
1 - Vertebral
2 - Costal
3 - Sternal
Diaphragm Muscle Parts : Vertebral
Right Crus - originate from bodies of 1st 3 lumbar vertabrae

Left Crus - originate from 1st 2 vertabrae only

Fibourous borders 2 crura form Median Arcurate Ligament in front of Aorta
Arcurate ligaments - Series of fibrous arches. (medial - cover Psoas Major / lateral - cover Quadratus Lumborum)
Diaphragm Muscle Parts : Costal
Attached to lower 6th ribs and costal cartilage
Diaphragm Muscle Parts : Sternal
2 small right and left slips from the posterior surface of xiphoid process
Diaphragm Central Tendon
- Insertion site for muscle fibers.

- Shaped like 3 leaves
Partially fused with inferior aspect of pericardium
Diaphragm Nerve Innervation
Left and Right Phrenic Nerve which innervate at C3-4-5.
Sensory fibers run in phrenic nerve from central portion of diaphragm
List the 3 openings in the diaphragm and level of opening.
- Aortic - T12 (Aorta / Thoracic Duct / Azygos vein)

- Caval - T8 (IVC / Terminal branches of R phrenic nerve)
- Esophageal - T10 (Esophagus / R&L vagus / Esophageal branches of left gastric vessels / lymphatic from lower 1/3 of esophagus)
Diaphragm : Splanchniz Nerve
Greater / Lesser / Lowest Splanchnic nerve pierce crura.
Diaphragm : Sympathetic Trunks
Pass posterior to medial arcuate ligaments on each side.
Diaphragm : Superior Epigastric Vessels
Pass between the sternal and costal origins of diaphragm on each side
Diaphragm : Left Phrenic Nerve
Pierces left part of diaphragm
Neurovascular bundles of Intercostal Spaces 7 - 11 pass between muscular slips of costal origin.
Pleurae : Cavities
2 independent, non-communicating, right and left cavities.
Pleural Layers
Visceral - intimately related to surrface of lung
Parietal - lines inner wall of chest, upper surface of diaphragm, and sides of mediastinum and pericardium
Pleural Root
2 layers become continous
Pleural cuff hands down into loose fold as the pulmonary ligament
What is the space that seperates Parietal and Visceral layers?
Pleural Cavity (Pleural space)

What does the pleural space contain?
Pleural fluid
List the 4 Pleural Regions
1 - Costal
2 - Diaphragmatic
3 - Mediastinal
4 - Cervical
List the 2 Pleural Recesses
1 - Costodiaphragmatic
2 - Costomedistinal
Which layer of the pleura is sensative to pain, temp, touch, and pressure?
Parietal
Parietal Pleura Nerve Innervation : Costal Pleura
Intercostal Nerves
Parietal Pleura Nerve Innervation : Mediastinal
Phrenic Nerve
Parietal Pleura Nerve Innervation : Diaphragmatic
Lower 6 intercostal nerves
What is the hilus?
Opening that allows structures to move in and out of the pleural space.
Trachea Construction
4.5 to 5 inches long

1 inch in diameter
15 - 20 U-shaped cartilage

Cartilage is present anterior and deficien posterior
Trachea Positional Landmarks
Superior - C6 (lower border of crichooid cartilage)

Inferior - T4 (Sternal Angle)
Tracheal Relation : Structures Anterior to Trachea
- Sternum
-Thymus
- L brachiocephalic Vein
- Origin Brachiocephalic Art
- Origin L Common Carotid Art
-Aortic Arch
Tracheal Relation : Structures Posterior to Trachea
- Esophagus
- L Recurrent Laryngeal Nerve
Tracheal Relation : Structures to Right Side of Trachea
- Azygos vein
- R Vagus Nerve
- Pleura
Tracheal Relation : Structures to Left Side of Trachea
- Arch of Aorta
- L Common Carotid Art
- L Subclavian Art
- Pleura
- L Phrenic Nerve
- L Vagus Nerve
Right Main Stem Bronchi
Wider, shorter, more vertically oreinted than L MSB
About 1 inch long after bifurcation at carina
Right Main Stem Bronchi Location at entrance to lung.
T5

What is specific to the Right Main Stem before joining the lung?
Right main stem branches off to the superior lobe of the lung prior to joining the lung.
Right Main Stem Bronchi after entering Hilum.
Branches off into middle and inferior lobar bronchi.
Left Main Stem Bronchi
Narrower, longer, and more horizontally oriented compared to R MSB
About 2 inches long after bifurcation at carina
Left Main Stem Bronchi Location at entrance to lung
Reaches hilum at T6

Where does the L MSB lie compared to L Pulmonary Art?
Behind and then below L Pulmonary Artery
Left Main Stem Bronchi Position
Passes to left below Arch of Aorta, in front of Esophagus and Descending Aorta
Lungs : Apex
Projects into the neck above clavical and sternal edge of 1st rib
Lungs : Base
Overlies the diaphragm
Lungs : Costal Surface
Molded to lateral chest wall
Lungs : Medistinal Surface
Molded to pericardium and mediastinal structures
Lungs : Hilum
Depression located at the middle of mediastinal surface.
Location where bronchi, vessels, and nerves that form the root enter/leave the lung.
Lung : Right
Larger than Left (Duh - No heart)
Contains 3 lobes.

Superior / Middle / Inferior
Lung : Left
Smaller than Right (Duh - there is a heart)
Contains 2 lobes

Superior / Inferior Lobes
What Fissure is responsible for forming the Superior and Inferior Lobes?
Oblique
What Fissure is responsible for forming the Middle Lobe in the Right Lung?
Horizontal Fissure
Lungs : Pulmonary Blood Supply (Venous)
Pulmonary Arteries - Terminal branches supply alveoli with unoxygenated blood
Only artery to carry deoxygenated blood

Blood from heart to lung
Lungs : Pulmonary Blood Supply (Arterial)
Pulmonary Veins - Brings oxygenated blood back from the lungs to L atrium.
Only vein to carry oxygenated blood

Blood from lung to heart
Lungs : Bronchial Blood Flow (Ateries)
Branches of descending aorta supply blood to bronchi, connective tissue and visceral pleura.
Lungs : Broncial Blood Flow (Veins)
Drain venous blood flow from bronci, connective tissue, and visceral pleura into azygos and hemiazygos veins.
On average, how many alveolar ducts are there?
14 million

On average, how many capillaries exist in the lung?
280 Billion
Lungs : Nerve Supply
Pulmonary Plexus

Afferent and efferent autonomic nerve fibers
How is the pulmonary plexus formed?
By branches of the sympathetic trunk and receives parasympathetic fibers from Vagus Nerve
What effect does the sympathetic nervous system have on bronchi?
Increases the size of bronchi to increase air flow.
What effect does the parasympathetic nervous system have on bronchi?
Reduces size of bronchi. Decrease need for air flow.
WIth regards to asthma, how can you treat bronchoconstriction?
Give a Sympathomemetic drug to increase bronchial size.
Give a parasympathetic blocker to prevent relaxation of bronchi.
Broncho-Pulmonary Segments : Right Superior Lobe (3)
1 - Apical
2 - Posterior
3 - Anterior
Broncho-Pulmonary Segments : Right Middle Lobe (2)
1 - Lateral
2 - Medial
Broncho-Pulmonary Segments : Right Inferior Lobe (5)
1 - Superior (Apical)
2 - Medial Basal
3 - Anterior Basal
4 - Lateral Basal
5 - Posterior Basal
Broncho-Pulmonary Segments : Left Superior Lobe (5)
1 - Apical
2 - Posterior
3 - Anterior
4 - Superior Lingular
5 - Inferior
Broncho-Pulmonary Segments : Left Inferior Lobe (5)
1 - Superior (Apical)
2 - Medial Basal
3 - Anterior Basal
4 - Lateral Basal
5 - Posterior Basal
Broncho-Pulmonary Segments
Each segment is supplied by a segmental brochus, artery, and vein.
(4) Medistinal Borders
Superior - Thoracic inlet

Inferior - Diaphragm
Anterior - Sternum

Posterior - Vertebral Column
Medistinal Contents (8)
1 - Thymus
2 - Heart / Large Vessels
3 - Trachea
4 - Esophagus
5 - Thoracic Duct
6 - Vagus Nerve
7 - Phrenic Nerve
8 - Sympathetic Trunk
Mediastinal Divisions
Superior

Inferior
What seperates the 2 mediastinal divisions?
Plane between the sternal angle (anterior) and lower border of 4th vertebral body (Posterior)
Superior Medistinal Contents from anterior to posterior.
Thymus, large veins, large arteries, trachea, esophogus and thoracic duct, sympathetic trunk
Inferior Medistinal Contents from anterior to posterior.
Thymus, heart w/in pericardium, phrenic nerves on each side of heart, esophagus and thoracic duct
descending aorta, sympathetic trunks
Superior Medistinal Borders
Anterior - Manubrium

Posterior - Thoracic Vertebra 1-4
Superior - Root of neck

Inferior - 3 Compartments of the Inferior Medistinum
Contents Inferior Mediastinum : Middle
Pericardium and Heart
Contents Inferior Mediastinum : Anterior
Space between pericardium and sternum
Contents Inferior Mediastinum : Posterior
Between paricardium and lower 8 thoracic vertebra
Superior Mediastinum : Aorta
Main arterial trunk from the heart.
List the three parts of the Aorta.
1 - Ascending Aorta
2 - Aortic Arch
3 - Descending Aorta
Ascending Aorta
- Lies in fibrous pericardium.
- Enclosed with pulmonary trunk in sheath of serous pericardium
- At root is bulge (Sinus of Aorta)
Which section of the Aortic Sinus does the Right Cornary Artery Arise?
Anterior Aortic Sinus
Which section of the Aortic Sinus does the Left Cornary Artery Arise?
Posterior Aortic Sinus
Where does the Ascending Aorta begin?
Base of the left ventricle. (Remember that the base is on the top of the heart and apex is on the bottom)
What path does the ascending aorta travel?
Up from the left ventricle, runs upward and forward behind R half of sternum at level of sternal angle.
List the three branches off the aortic arch.
1 -Brachiocephalic Artery
2 -Left Common Carotid
3 -Left Subclavian Artery
What does the Brachiocephalic Artery bifurcate into?
1 -R Subclavian Artery
2 -R Common Carotid
Which side of the trachea does the Brachiocephalic artery exist?
Right
Describe the travel path of the Left Common Carotid Artery in the thoracic cavity.
Upward and L of the trachea.
Describe the travel path of the Left Subclavian Artery in the thoracic cavity.
Rund upward along the left side of trachea and esophagus to enter the neck.
What anitomical structure does the L Subclavian cross over?
Apex of Left Lung
Describe the travel path of the aortic arch.
Continuation of ascending aorta. Lies behind the manurium. Arches upward, back and to the left in front of trachea.
Then downward to the left where it joins with the descending aorta at the level of the sternal angle.
Describe location of the Descending Aorta.
Posterior Mediastinum.
Where does the descending aorta start?
Level of the sternal angle. It is a contiunation of the aortic arch.
Describe the travel path of the descending aorta after the sternal angle.
Angles forward and medially to rach the anterior vertebral column.
What level does the descending aorta pass through the diaphragm?
Level of the 12th thoracic vertebra.
Where does the descending aorta become the abdominal aorta?
Roughly T12, after passing through diaphragm.
What is the function of the Pulmonary Trunk?
Sends deoxygenated blood from the R Ventricle to lungs.
What shrouds the Pulmonary trunk?
Enclosed in a sheath of serous and fibrous pericardium.
What is enclosed within the serous and fibrous pericardium with the pulmonary trunk?
Ascending aorta.
Where does the pulmonary trunk terminate?
Concavity of the Aortic Arch.
What does the pulmonary trunk become at its termination point?
- R pulmonary artery
- L pulmonary artery
Describe the projection of the R Pulmonary Artery.
Right posterior to the ascending aorta and SVCto enter root of R lung.
Describe the projection of the L Pulmonary Artery.
Left anterior to descending aorta to enter the root of L lung.
What forms the R brachiocephalic vein?
Union of R subclavian and R internal jugular.
What forms the L brachiocephalic vein?
Union of L subclavian and L internal jugular.
What do the R and L brachiocephalic veins become?
SVC - Superior Vena Cava
Where does the blood entering the SVC come from?
All venous blood from the upper extremities, head, and neck.
Where does the SVC enter the R atrium?
Ineriorly to R atrium.
What three veins form the Azygos Venous System?
1 -Azygos Vein
2 -Hemiazygos Vein
3 -Accessory Hemiazygos Vein
What blood returns in the azygous system? (Yes, venous. But from where?)
Name all 6.
- Posterior part of intercostals
- Posterior abdominal wall
- Pericardium
- Diaphragm
- Bronchi
- Esophagus
Describe position and origin of the Azygos Vein.
Variable origin and numerous tributaries. Normally in the R side of the chest on R side of Aorta.
Azygos vein direction of travel.
Ascends through the aortic opening of the diaphragm traveling from inferior to superior. To the level of the 5th thoracic vertebra.
Describe the termination of the Azygos vein.
Arches above the root of the R lung and empties into posterior surface of SVC.
Describe origin of the Hemiazygos system.
Left side by junction of L subcostal and ascending lumbar veins.
Describe the travel path of the Hemiazygos Vein.
Ascends on the L side of vertebral column, posterior to the thoracic aorta.
Where (in genral in a normal system) does the hemiazygos system cross to the Azygos system?
Level of T9.

Traveling from L to R.
What is the travel path of the Accessory Hemiazygos Vein originate?
Travels from superior to inferior on the L side of vertebral column.
Where (in general, in a normal system) does the Accessory Hemiazygos Vein terminate?
Connects to the Azygos system. May join with the Hemiazygos system.
Where does the Accessory Hemiazygos system transverse and connect to the Azygos system?
Crosses over at the 7th thoracic vertebra.
Roughly, how long is the esophagus?
10 inches
Where does the esophagus lie?
Extends from the lower border of the crichoid cartilage to cardiac orifice of the stomach.
Esophagus arterial supply.
- Inferior thyroid artery
- Branches of descending thoracic aorta
- L gastric artery
Esophagus venous drainage.
- Inferior thyroid vein
- Azygos
- L gastric vein
Name the 3 layers of connective tissue from outer to inner.
1 -Outer connective sheath
2 -Muscular layer of external longitudinal / internal circular fibers.
3 -Submucosal layer
What section of the esophagus has striated muscle fibers?
Upper 2/3
What section of the esophagus ahs smooth muscle fibers?
Lower 1/3
What does the submucosal layer contain?
- Mucous glands
- Mucosal layer of stratified epithelium
What is the function of the thoracic duct?
- Main lymph duct
- Returns lymph back to circulating blood volume
Where in the body does the Thoracic Duct drain lymph?
- Entire lower body
- Left Thorax
- Left arm
- Left side of head and neck
Describe the origination of the thoracic duct.
Begins in the abdomen as a dilated sac (cisterna chyli).
Describe the path of travel for the thoracic duct.
Ascends through aortic opening in diaphragm, to the right of the descending aorta.
Crosses midline behind esophagus and runs left edge of esophagus to enter root of the neck.
Where does the thoracic duct terminate?
Crosses the subclavian artery and enters the L brachiocephalic vein.
Left Vagus Nerve
Descends in left chest betweeen left common carotid and left subclavian artery.
Where does the L Vagus Nerve cross the Aorta?
Crosses over left side of aortic arch and turns behind the root of the left lung.
What does the L vagus nerve become after it passes the root of the left lung?
Pulmonary plexus.
What does the left vagus nerve become at the level of the esophagus?
Esophogeal plexus.
Where does the esophageal plexus lie?
Anterior portion of esophagus
Where does the L vagus nerve pass into the anterior stomach?
Through the esophageal opening on the anterior portioin of the esophagus and inervates the anterior stomach.
How does the R vagus nerve travel.
Descends the thorax passing behind the root of the R lung, where it forms the pulmonary plexus.
Where does the R Vagus nerve become the esophageal plexus and where does it lie?
As it touches the esophagus and lies on the Posterior esophagus.
Where does the R vagus nerve pass into the posterior stomach?
Through the diaphragmatic opening on the back of the esophagus.
What do the bracnhes of the Vagi supply?
Both supply the lungs and the esophagus.
What does the right branc of the Vagi give off?
Cardiac branches
What does the Left vagus nerve give off?
Left recurrent laryngeal nerve.
What is the path of the Left recurrent nerve?
Comes off the L Vagus nerve and turns around the ligamentum arteriosum prior to ascending between the trachea and esophagus
What does the Left laryngeal nerve supply?
Most muscles of left vocal cord.
Where do the Phrenic nerves originate?
Ventral rami or cervical nerves 3,4,5.

(C 3,4,5 keep diaphragm alive)
Are the Phrenic nerves afferent or efferent in nature?
Both afferent and efferent.
What are the sole nerve suppply of the diaphragm?
Phrenic nerves.
Desrcibe path of R phrenic nerve.
Descneds thorax on right side superior to the SVC. Passes in front of R Lung root. Is attached to R side of paericardium.
Where does the R vagus nerve pass through the diaphragm?
Caval opening.
What does the R phrenic nerve supply?
Central Peritonium.
Desrcibe path of L phrenic nerve.
Descends the thorax on the left side of left subclavian. Crosses the left side of arotic arch. Passes in front of L root of lung. Attached to L side of pericardium.
What does the R phrenic nerve supply?
Central Peritoneum
Where is the thoracic sympathetic trunk with regards to cervical and lumbar sections?
Lies between the cervical and lumbar sections.
Where is the sympathetic trunk located?
Medially in mediastinum and runs on the heads of the ribs.
Components of the sympathetic trunk.
12 (sometimes 11) segmentally arranaged ganglia with white and gray ramus communications to spinal nerve.
What is specific to the first thoracic ganglia?
I tis fused with the inferior cervical ganglion to form stellate ganglion.
Thoracic Sympathetic Trunk Branches : Postganglionic Fibers.
From T1-T5 are distributed to heart, aorta, lungs and esophagus.
Thoracic Sympathetic Trunk Branches : Preganglionic Fibers.
From T5-T12 form splanchnic nerves.
Where do the splanchnic nerves pierce the diaphragm and waht do they supply?
Pierce the Crura and supply the abdominal viscera.
Where does the Greater Splanchnic Nerve run?
T5-T9
Where does the Lesser Splanchnic Nerve run?
T10-T11
Where does the Least Splanchnic Nerve run?
T12
Thoracic Sympathetic Trunk Branches : Communications
Gray Rami communications for to all thoracic spinal nerves. Postganglinoic fibers are distributes with branches of spinal nerve to skin.