Pulmonary lymphatic drainage

There are two types of lymphatic vessels in the lungs. The superficial vessels run along the margins of fissures and end in the bronchopulmonary nodes. The deep efferents pass to the hilum of the lungs to reach the same bronchopulmonary nodes. The vessels which drain the bronchial tree follow a pattern. Lymphatic vessels of the upper lobe end up in the superior tracheobronchial nodes, while those in the lower lobe enter the inferior tracheobronchial nodes. The tracheobronchial and bronchopulmonary nodes all end in the bronchomediastinal lymph trunk. This trunk reaches the thoracic duct on the left and the right lymph duct on the right or the right jugulosubclavian junction.

Intrapulmonary lymph nodes –> left and right bronchopulmonary (hilar) lymph nodes –> carinal lymph (inferior tracheobronchial) nodes –> tracheobronchial lymph nodes –> paratracheal lymph nodes –> jugular trunk –> thoracic duct

An unusual feature of this anatomy is that carinal nodes, collect lymph from the left lower lobe but drain that fluid into the right tracheobronchial lymph nodes. This is significant because a suspicious-appearing lymph node in the right hilar region should prompt evaluation of the left lower lobe and the right lung.

Trachea volume

Trachea volume

-Diameter 16 mm
-length 100 mm
-volume = 20 cc คิดจากปริมาตรทรงกระบอก

ถ้าเป็น COPD จาก CT เห็นเป็น saber-sheath trachea เป็นดาบ

Bleb Bullae Cyst

BLEB

1 cm
-Pathology.—An airspace measuring more than 1 cm usually several centimeters in diameter, sharply demarcated by a thin wall that is no greater than 1 mm in thickness. A bulla is usually accompanied by emphysematous changes in the adjacent lung.
-Bullae may contain nothing but gas or may contain overdistended and ruptured alveolar septa and blood vessels
Radiographs and CT scans.—A bulla appears as a rounded focal lucency or area of decreased attenuation, 1 cm or more in diameter, bounded by a thin wall.Multiple bullae are often present and are associated with other signs of pulmonary emphysema

CYST

-Pathology.—A cyst is any round circumscribed space that is surrounded by an epithelial or fibrous wall of variable thickness (51).
-Radiographs and CT scans.—A cyst appears as a round parenchymal lu- cency or low-attenuating area with a well-defined interface with normal lung. Cysts have variable wall thickness but are usually thinwall (<2 mm) and occur without associated pulmonary emphysema (Fig 21). Cysts in the lung usually contain air but occasionally contain fluid or solid material. The term is often used to describe enlarged thin walled airspaces in patients with lymphangioleiomyomatosis (52) or Langer- hans cell histiocytosis (53); thicker walled honeycomb cysts are seen in patients with end-stage fibrosis

EMPHYSEMA

-Pathology.—Emphysema is characterized by permanently enlarged airspaces distal to the terminal bronchiole with destruction of alveolar walls (42,43). Absence of “obvious fibrosis” was his- torically regarded as an additional crite- rion (42), but the validity of that criterion has been questioned because some interstitial fibrosis may be present in emphysema secondary to cigarette smoking (56,57). Emphysema is usually classified in terms of the part of the acinus predominantly affected: proximal (centriacinar, more commonly termed centrilobular, emphysema), distal (paraseptal emphysema), or whole acinus (panacinar or, less commonly, panlobular emphysema).
-CT scans.—The CT appearance of emphysema consists of focal areas or regions of low attenuation, usually without visible walls (58).presenting bronchovasular bundle in central area. In the case of panacinar emphysema, decreased attenuation is more diffuse

Phrenic nerve

The phrenic nerve descends obliquely with the IJV across the anterior scalene, deep to the prevertebral layer of deep cervical fascia and the transverse cervical and suprascapular arteries. On the left; the phrenic nerve crosses anterior to the first part of the subclavian artery. On the right; it lies on the anterior scalene muscle and crosses anterior to the 2nd part of the subclavian artery. On both sides, the phrenic nerve runs posterior to the subclavian vein and anterior to the internal thoracic artery as it enters the thorax.
Found in the middle mediastinum, both phrenic nerves run from C3, C4 and C5 along the anterior scalene muscle deep to the carotid sheath.
The right phrenic nerve passes over the brachiocephalic artery, posterior to the subclavian vein, and then crosses the root of the right lung anteriorly and then leaves the thorax by passing through the vena cava hiatus opening in the diaphragm at the level of T8. The right phrenic nerve passes over the right atrium.
The left phrenic nerve passes over the pericardium of the left ventricle and pierces the diaphragm separately.

Intercostal muscle

Scalene m.

SVC obstruction

Classification based on location of SVC obstruction
Pre-azygous or supra-azygous

Obstruction of blood return above the entrance of azygous vein into the SVC, resulting in venous distension and oedema of the face, neck, and upper extremities.

Post-azygous or infra-azygous

Obstruction below the entrance of azygous vein into the SVC results in retrograde flow through the azygous via collaterals to the inferior vena cava, resulting in not only the symptoms and signs of pre-azygous disease, but also dilation of the veins over the abdomen.

This is usually more severe and poorly tolerated than pre-azygous obstruction.

Cisterna chyli

cisterna chyli is an irregularly shaped chamber about 6 cm (2½ inches) long and about 2.5 cm (1 inch) wide which lies on the rear wall of the abdominal cavity. The intestinal lymph trunk, which carries the lymph from the intestines, and the left and right lumbar trunks, which carry lymph from the lower limbs and the pelvis, lead into it. At its upper end it narrows to form the lower end of the thoracic duct.

Lt thoracic duct empty into the junction of the left subclavian vein and left jugular vein, below the clavicle, near the shoulders.

Rt thoracic duct เข้า rt subclavien v รับจากหน้าตัว แขนขวา

Tip scapular T7 Spine T3

Vascular pedicle width

 

point at which the superior vena cava intersects the right main bronchus an a line drawn at the takeoff of the left subclavian artery from the aorta

it is usually normal in acute cardiac failure and wide in overhydration/renal failure pulmonary edema and chronic heart failure. In can be normal or narrowed in capillary permeability pulmonary edema.

becoming wider with an anteroposterior view. Body position may also alter this measurement, such that an increase in the vascular pedicle width occurs when moving from upright to supine positions as well as torso rotation to the right.

สรุปท่านั่ง >53 mm ท่านอน > 64 mm