CLINICAL ANATOMY OF

RESPIRATORY SYSTEM

Dr. Ridwan Harrianto MHSc(OM),Sp.Ok

Organs of the Respiratory System
 The Paranasal Sinuses
 Maxillary sinus 
middle meatus .
The floor is thin  upper
teeth (teeth 6 to 8)

 Ethmoidal sinus
(ethmoidal cells)
Anterior group  middle
meatus
Posterior groups 
superior meatus

 Frontal sinus  middle

meatus

 Sphenoidal sinus 
meatuses superior.
 Trachea
 The windpipe (10 – 12
cm)
 The rings of cartilage (16
– 20) to help keep the
airways open (2.5 cm).
 Lined with mucus
membranes which add
moisture to the air
 Lined with cilia that
sweep mucus and small
particles back up the
airway.
 In the mediastinum ( 5th
Th, the sternal angle.)
divides into the right and
Bronchial tree
 Primary bronchi
(main bronchi)
 Largest bronchi
 Right main
bronchi - wider
and shorter than
the left
 Secondary (lobar)
bronchi
 Three on the right
 Two on the left
 Tertiary (segmental)
bronchi - branch
into each lung
segment
 Bronchioles - little
bronchi, less than 1
mm in diameter
 Terminal
bronchioles - less
Main Bronchus
Segmental bronchus
 Lobes and Surfaces of the
lobes lungs
 Right lung has three

 Left lung has two lobes

 Concavity on medial
surface = cardiac notch
 Bronchi enter the lungs
at the hilus
Mediastinal surface
 Pleura
 The outer pleura (parietal
pleura) covers and is
attached to the chest wall.
 The inner pleura (visceral
pleura) covers and is
attached to the lung and
other structures, i.e. blood
vessels, bronchi and nerves.

 Between the two is a thin

space known as the pleural
space/pleural cavity,
 which normally contains a
small amount of pleural
fluid (12-15 mL)

 The parietal pleura is highly

sensitive to pain;
 the visceral pleura is not,
because it receives no
  The apices of the Lungs 2-3
Thorax surface cm above the medial thirds of
the clavicles. Meeting each
marking other in midline at 2nd rib (the
sternal angle)  Diverge at 4th
The Lung rib

On the right side:

 Down as far as the 6th costal
cartilage  Turns laterally to
meet the midclavicular line at
the 6th rib  The midaxillary
line at the 8th rib  The
scapular line at 10th thoracic
vertebra
[ 2 – 4 – 6 - 6 – 8 – 10 ] 
A line ascends along the
paravertebral line to join the apex

On the left side:

Thorax surface marking -
The Pleura
The lower borders of the
lungs
 8th rib in the midclavicular
line,
 10th rib in the midaxillary
line
 12th thoracic vertebra
 in paravertebral line)
 [ 2 – 4 – 6 - 6 – 8 – 10 -
12]
surface The Lung

marking On the right side:

[ 2 – 4 – 6 - 6 – 8 – 10 ]
On the left side:
[ 2 – 4 - 6 – 8 – 10 ]

The Pleura
[ 2 – 4 – 6 - 6 – 8 – 10 - 12]

The Heart
 2nd left rib
 3rd right rib
 6 right rib [parasternal line]
 5th intercostal space
midclavicular line
 Lung fissure surface marking

Medial border of abducted scapula

Oblique fissure: 3rd Th posteriorly  6th rib anteriorly [ 3 – 6 ]
Horizontal fissure: 4th rib (costal cartilage) medial  5th rib (axillary line)
Pleural puncture The posterior approach
better than the anterior
approach.
• The posterior gutter deep
the fluid tends to
accumulate in the erect
position
• The interspaces are wider in
the back.
• The neurovascular bundle is
closer to the inferior margin
of the rib posteriorly
• The collateral branch of
posterior intercostal artery
is much smaller than the
main vessels  insert the
Theneedle
anterior approach.
close to the upper
border
 The of theintercostal
anterior rib.
arteries are more equal
size  insert the needle in
the center of the
 Pleural
 Thepuncture
ideal interspace is
the 7th, 8th or 9th space,
midway between the
posterior axillary line and
midline.
 This site avoids possible
accidental puncture of
the liver, spleen,
diaphragm and
descending aorta, or
 Alternatively :
The 1-2 interspace below
the upper limit of
dullness/by chest X-ray
or chest ultrasound
 Kronig’s isthmus
 The narrow strap like portion
of the resonant field that
extends over the shoulder to
the base of neck over the
pulmonary apex
(supraclavicular region)

 A. Anterior: Medial 2/3 of the

clavicle.
 B. Posterior: Medial 1/3 of
spine of scapula.
 Medial: A line joining
sternoclavicular joint with the
7th cervical spine posteriorly.
 Lateral: A line joining point A
and point B

 Dullness of this area suggest

upper lobe disease
Traube’
s area The area of tympanitic
resonance
overlying the fundus of the
stomach :
 Upper border: Base of the
Left Lung.
 Lower border: Left Costal
Margin
 Left border: Anterior
border of spleen
 Right border: Lower border
of left lobe of liver

Dullness in this area:

 Left pleural effusion.
 Left basal consolidation.
 Enlarged left lobe of the
liver.
 Bare area of Heart
The area of dullness
overlying the heart
 An area extending
from the 4th to the 6th
costal cartilages and
from the left sternal
border to the left
parasternal line
Resonant in this area:
 emphysema
 left sided
pneumothorax.
 Radioanatomy
PA View
1. Aortic arch
2. Pulmonary
trunk
3. Left atrial
appendage
4. Left ventricle
5. Right
ventricle
6. Superior
vena cava
7. Right
hemidiaphra
gm
8. Left
hemidiaphra
gm
9. Horizontal
fissure
Radioanatomy PA
View
 The silhouette sign
 Intra-thoracic radio-opacity
border  contact with a
border of heart, aorta or
diaphragm
 The loss of the normal
radiographic contour
between :
the right lower + middle lobes
pneumonia

right heart + right diaphragm

border
Bronchial Blood Supply
 Bronchial arteries
 From aorta to terminal
bronchioles

 Merge with pulmonary arteries

and capillaries

 1% of total cardiac output (left

ventricle)

 Also nourish
 Mediastinal lymph nodes
 Pulmonary nerves
 Some muscular pulmonary
arteries and veins
 Portions of the esophagus
 Visceral pleura
 Bronchial venous system
 1/3 blood returns to right heart
 Azygous
 Hemiazygous
 Intercostal veins

 This blood comes form the first

two or three generations of
bronchi
 2/3 of blood flowing to terminal
bronchioles drains into
pulmonary circulation via
“bronchopulmonary
anastomoses”
 Then flows to left atrium via
pulmonary veins
 Contributes to “venous
admixture” or “anatomic shunt”
(ca. 5% of C.O.)
Pulmonary Vascular System
 The second source of blood
to the lungs
 Primary purpose is to
deliver blood to lungs for
gas exchange
 Also delivers nutrients to
cells distal to terminal
bronchioles
 Composed of arteries,
arterioles, capllaries,
venules, and veins
 Pulmonary Capillaries
Walls are les than 0.1µ thick
Total external thickness is about 10µ
Selective permeability to water, electrolytes, sugars
Produce and destroy biologically active substances
 Pulmonary lymphatic
 The lymphatic drainage of the lungs
start with lymphatic vessels that first system
drain into intraparenchymal
lymphatics and lymph nodes, then
move to peribronchial (hilar) lymph
nodes, and subsequently move to
subcarinal, tracheobronchial, and
paratracheal lymph nodes
 The lymphatics eventually
communicate with the venous system
via the bronchomediastinal lymphatic
trunk and the thoracic duct or via the
inferior deep cervical (scalene) lymph
nodes.
 However, some variants of the
lymphatic drainage are very important
to consider overall in the
dissemination of pulmonary
neoplasms
 ALIRANGETAHBENINGPARU(2)

Nn. Lymphatici Peribronchial (Hilar)

Nn. Lymphatici Tracheobronchiales

Nn.ll. Tracheobronchiales Inf.  dalam sudut antara Bronchus Dx & Sin.
Nn.ll. Tracheobronchiales sup. dx.  di sudut antara Bronchus Dx. & Trachea
Nn.ll. Tracheobronchiales sup. sin.  di sudut antara Bronchus Sin. & Trachea

Nn. Tracheales / Paratracheales

Truncus Bronchomediastinalis dx. ke cranial

Ductus Thoracicus
Nn.ll. Cervicales Profundi inf.

Ductus Lymphaticus Dx.

Bulbus V. Jugularis Inf. Dx.

(Angulus Venosus Dx.)