Tractus Respiratorius

dr. Zainuri Sabta Dep. Anatomi FK UII

Paranasal Sinuses
Four bones of the skull contain paired air spaces called the paranasal sinuses - frontal, ethmoidal, sphenoidal, maxillary Decrease skull bone weight Warm, moisten and filter incoming air Add resonance to voice. Communicate with the nasal cavity by ducts. Lined by pseudostratified ciliated columnar epithelium.

Frontal sinus Ethmoidal sinuses Sphenoid sinus

Maxillary sinus

Right and Left Pleural Cavities

Parietal Pleura Visceral (Pulmonary) Pleura Parietal

Costal Mediastinal Diaphragmatic Cupola

Connecting Pleura

Proyeksi external paru

Lungs

Light, soft, spongy Conical in shape, apex, base, costal surface, medial surface, hilus. Note various impressions Right lung
Three lobes; superior, middle and inferior Oblique and horizontal fissure

Left Lung

Two lobes; superior and inferior also Lingula and Cardiac notch, horizontal fissure

Struktur yang keluar/masuk hilus pulmonis: 1. 2. 3. 4. 5. Bronchi a. & v. pulmonalis a. & v. bronchialis Vasa dan nodi lymphatici nervus

Lungs formed by progressive branching, first 16 generations of airways = conducting zone, generations 16-23 = gas exchange zone 300 million alveoli (0.3 mm in diameter), total surface area 85 m2, 0.4 m2 if lung a sphere Change in intrathoracic pressure moves air inspiratory muscles (diaphragm, external intercostals, accessory = SCM, scalene) size of thorax intrathoracic pressure relative to atmospheric pressure bulk flow into airways (flow = pressure gradient / resistance)

Inervasi diaphargma

Trachea

Bronchus:
Vascularisasi a. bronchialis cab. Aorta (2 cabang kiri, 1 kanan) Drainase vena kanan : v .azygos kiri: v. hemiazygos (sebagian kecil via v. bronchiales dan v. pulmonale)
Sympathis vasokonstriksi, bronchodilatasi (beta 2 ), supresi sekresi kelenjar (alpha) Parasympathis vasodilatasi, bronchokonstriksi, peningkatan sekresi kelenjar , sensasi

Lungs have large surface area & thin membrane for gas exchange, formed by progressive branching (vascular and air spaces brought close together), first 16 generations of airways = conducting zone, generations 16-23 = gas exchange zone 300 million alveoli (0.3 mm in diameter), total surface area 85 m2, 0.4 m2 if lung a sphere Change in intrathoracic pressure moves air inspiratory muscles (diaphragm, external intercostals, accessory = SCM, scalene) size of thorax intrathoracic pressure relative to atmospheric pressure bulk flow into airways (flow = pressure gradient / resistance)

Airways
Trachea, primary bronchi, secondary bronchi, tertiary bronchi out to 25 generations All comprised of hyaline cartilage Trachea
Begins where larynx ends (about C6) 10 cm long, half in neck, half in mediastinum 20 U-Shaped rings of hyaline cartilage keeps lumen intact but not as brittle as bone Lined with epithelium and cilia which work to keep foreign bodies/irritants away from lungs

Airways
Primary Brochi
One to each lung continuation of trachea Right bronchus is wider and shorter 2.5 cm as opposed to 5 cm and branches from the trachea at a greater angle

Secondary bronchi one to each lobe, three in right, two in left Tertiary one to each bronchopulmonary segment approximately 10 per lung All of the above are hyaline cartilage with no ability to change diameter

Bronchioles
First level of airway surrounded by smooth muscle; therefore can change diameter as in brocho-constriction and broncho-dilation Bronchioles Terminal Bronchioles Respiratory
3-8 orders

alveoli

Conducting zone vs. respiratory zone

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Conducting zone functions

Regulation of air flow trachea & bronchi held open by cartilaginous rings smooth muscle in walls of bronchioles & alveolar ducts sympathetic NS & epinephrine relaxation ( receptors) air flow leukotrienes (inflammation & allergens leukotrienes mucus & constriction) Protection mucus escalator (goblet cells in bronchioles & ciliated epithelium) inhibited by cigarette smoke Warming & humidifying inspired air expired air is 37 & 100% humidity (loss of ~400 ml pure water/day) Phonation larynx & vocal cords

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Alveolar structure 2

Pulmonary capillaries completely surround each alveolus; sheet of blood Interstitial space diffusion distance for O2 & CO2 is less than diameter of red blood cell Elastic fibers secreted by fibroblasts into pulmonary interstitial space tend to collapse lung

Alveolar structure 3

Type I epithelial cells thin, flat; gas exchange Type II epithelial cells secrete pulmonary surfactant pulmonary compliance (later)

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Inhalasi Partikel Asing

Stage 1
7 microns & above

Stage 2
4,7-7 microns

Stage 3
3,3-4,7 microns

Stage 4
2,1-3,3 microns

Stage 5
1,1-2,1 microns

Cairan mukus, cilia, reflex batuk dan sel darah putih (macrophages) merupakan protector paru terhadap pengaruh benda asing dari luar misal: debu, kotoran, bakteri, asap rokok dll.
Stage 6
0,6-1,1 microns

Besar-kecilnya dampak partikel yang masuk paru bergantung pada sejumlah faktor: konsentrasi partikel di udara dengan diameter kurang dari 10 mikron, frekuensi dan lama pemaparan, kandungan partikel, cuaca, dan kondisi kesehatan seseorang.

EFEK TERHADAP KESEHATAN

Inhalasi debu mineral secara umum disebut Pneumoconiosis.

Silicosis adalah penyakit paru akibat inhalasi debu yang mengandung cristal silica (alpha-quartz or silicon dioxide), atau silica tipe polymorphs (tridymite or cristobalite), yang secara alami terdapat pada dan memiliki toksisitas sangat tinggi terhadap paru. Gejala silikosis umumnya muncul beberapa tahun setelah terkena paparan. Sebagai contoh pekerja terpapar silica selama 30 tahun, dimana terjadi fibrosisasi jaringan paru hebat.

EFEK TERHADAP KESEHATAN

Mekanisme Kerusakan paru
Partikel < 1 mikron
Terjadi kerusakan membran sel epitel alveoli melalui mekanisme peroksidasi lipid dan dan inaktivasi protein esensial sel Macrophag alveoli memakan partikel, teraktivasi dan merangsang pengeluaran cytokines, termasuk tumor necrosis factor, interleukin-1, and leukotriene B-4, dan terjadilah proses radang (inflamasi) yang menyebabkan kerusakan sel dan matrik alveoli. Pada tahap selanjutnya merubah growth factor alpha induces proliferation of type 2 pneumocytes, and other cytokines (eg, plateletderived growth factor, insulin - like growth factor) dan merangsang sel fibroblas berproliferasi memproduksi collagen dan akhirnya terjadi fibrosis paru.

Permukaan partikel merangsang terbentuknya radikal bebas (hydroxyl, hydrogen peroxide, and other oxygen radicals)

Innervation
Pleura via intercostal (thoracic) nerves Tracheobronchial tree Parasympathetic via CN X efferent function = broncho-constriction via smooth mm., also to epithelial cells in trachea; afferent = responsible for cough reflex Sympathetic from T1-T5 efferent = brochodilation

Blood Supply
Lungs do not receive any vascular supply from the pulmonary vessels (pulmonary aa. Or veins) Blood delivered to lung tissue via the bronchiole arteries Vessels evolve from aortic arch Travel along the bronchial tree

Pharyngeal Arches (Brachial Arches)

General: develop during 4th week of gestation lateral swellings on either side of head; result from local proliferation of NCC give rise to specific cartilages and bones pharyngeal groovesexternal delineations between brachial arches; ectoderm covered pharyngeal pouchesinternal deliniation between brachial arches; endoderm lined closing membranesectoderm/endoderm contact points ensuring non-mixing between brachial arches

 Aortic Arch Arteries

blood vessel development follows path of least resistance (thru mesenchyme) => many run through brachial arches during early embryogenesis

Cranial Nerveseach is associated with a specific pharyngeal arch & innervates all its muscles, etc Muscleseach pharyngeal arch differentiates into a specific set of muscles which are innervated by the CN in that arch

Pharyngeal Arches
Arch 1 Artery Maxillary Nerve V(V2 & V3 only) Skeletal Elements (NCCs) Maxilla, mandible, zygomatic portions of temporal, (NCCs) Stapes, styloid process, part of hyoid (NCCs) Part of hyoid Muscles mm. of mastication (temporalis, masseter, pterygoids) myelohyoid, ant. belly of digastric, tensor tympani, & veli palatini muscles of facial expression, post. belly of digastric, stylohyoid, stapedius Stylopharyngeus

2 3

Stapedial (practically degenerates) Carotid Right: subclavian, Left: arch of the aorta Pulmonary

VII IX X (superior laryngeal br) X (recurrent laryngeal br)

(LPM) Laryngeal cartilages

Cricothyroid, levator veli palatine, pharynx constrictors

5 6

(LPM) Laryngeal cartilages

Intrinsic larynx mm.

Pharyngeal Pouches (Glands)

First Pharyngeal Pouch forms the auditory tube (narrow proximal part) & tympanic cavity (distal sac-like structure) tympanic membraneforms from lining of tympanic cav. later comes into contact with epithelial lining of 1st pharyngeal cleft (future EAM) Second Pharyngeal Pouch proliferates to form palatine tonsil Third Pharyngeal Pouch forms thymus and inferior parathyroid glands thymus descends during development, pulling superior/ inferior parathyroid glands with it Fourth Pharyngeal Pouch forms superior parathyroid glands attach to dorsal surface of thyroid Fifth Pharyngeal Pouch forms ultimobrachial bodyregulates Ca2+ in body & is embedded in thyroid

 Pharyngeal Grooves (Clefts)

four recognizable clefts; all but one disappear during development 1st pharyngeal cleft external auditory meatus (EAM) & part of tympanic membrane 2nd pharangeal arch mesenchyme proliferates overlapping arch that covers 2-4th pharangeal clefts smooth neck cervical sinustemporary cavity formed during development; closes later during development

Perkembangan paru, eophagus dan larynx

Paru berkembang dari Laryngotracheal groove, di mana pada cekungan tsb muncul laryngotracheal diverticulum yang selanjutnya menjadi Lung bud Bagian endoderma menjadi: bronchioli, pleura viseral, epithel larynx, trachea, glandula trachea, dan epithel bronchi. Trachea dan esophagus dipisahkan oleh septum. Bila gagal memisah akan membentuk fistula.

Kejadian Pulmo

ventilasi

 Obstructive lung disease = problem w/ airflow function of lung asthma, emphysema,chronic bronchitis, cystic fibrosis Restrictive lung disease = problem w/ gas exchange function of lung pulmonary fibrosis,pulmonary alveolar proteinosis

 Bronchi / bronchioles have minimal effect on airflow obstruction (but contribution to COPD via enlargement of bronchial mucus glands, goblet cells, airway smooth muscle hypertrophy Respiratory bronchioles major cause of obstruction macrophage inflammation, mucus plugs, loss of alveolar attachments (less alveolar septae tugging on airways and keeping them open distorted / collapsed bronchioles)

 Emphysema protease imbalance destruction of alveolar tissue loss of elastic recoil hyperinflation flattening diaphragm ( effort) dyspnea Dyspnea inactivity deconditioning dyspnea inactivity deconditioning disability Airflow limitation during exercise no ventilatory reserve, flow only by breathing at higher volumes dynamic hyperinflation; RR time to exhale hyperinflation SOB

 Emphysema
Abnormal permanent enlargement of alveolar spaces distal to terminal bronchiole w/ wall destruction, enlargement of alveoli (overinflation) Centrilobular involves respiratory bronchiles, upper lobes more involved, found inassociation w/ CB and smoking, spherical holes 1-5 mm near center of lobu Panlobular all portions of lobule affected but usually alveolar ducts, both upper/lower lobes involved, usually in middle-aged smokers or young pt. w/ antitrypsin (cotton candy lung)

 Pleuritis painful inflammation, usually w/ viral infections, also w/ bacteria, TB, PE, tumors Pneumothorax can have pleuritic pain as well, but dyspnea most common hyperresonant lung to percussion + breath sounds Examine pleural fluid to determine transudate or exudate (caused by infection, tumor, PE + infarct, collagen vascular disease, trauma, esophageal rupture, pancreatitis, abscess, ascites, asbestos, chylothorax, hypersensitivity)

 Exudate damage to pleura, leakage of plasma (protein, RBC, WBC) into pleural space, meets following criteria fluid protein / serum protein > 0.5, fluid LDH / serum LDH > 0.6, pleural fluid LDH > 2/3 of plasma (200 IU) continuum from pure transudate to exudates Empyema pus in pleural space, lots of PMN, seen w/ pneumonia (esp. anaerobic), occasionally seen w/ trauma, rarely w/ surgery Hemothorax blood in pleural space, due to trauma excessive blood loss hypotension Chylothorax lymph fluid (milky) in pleural space, due to poor lymphatic drainage (blockage), can be due to congenital atresia of thoracic duct, trauma from esophageal surgery, or tumor Pneumothorax injured chest wall (i.e. penetrating wounds, rib fracture), also due to insertion of central line, IJV or subclavian catheter, chest surgery, positive pressure ventilation air leaks in; spontaneous pneumothorax (primary no predisposition,

Pneumothorax injured chest wall (i.e. penetrating wounds, rib fracture), also due to insertion of central line, IJV or subclavian catheter, chest surgery, positive pressure ventilation air leaks in; spontaneous pneumothorax (primary no predisposition,