Essentials of Cardiopulmonary Physical Therapy PDF

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w w w.p th om eg ro up.c om  REGISTER TODAY! To access your Student Resources, visit: http://evolve.elsevier.com/Hillegass/cardiopulmonary/ om Register today and gain access to:.c Additional case studies: up ro Case studies which did not appear in the text are posted online to help students place new concepts in a clinical context. eg Archie animations: om These short, often narrated, film clips help explain or reinforce key ideas. Glossary: th A glossary of key terms from the book has been posted online as a quick-reference guide for students..p Glossary activities: w Wordplay games using terms from the glossary give students a fun way to retain a new vocabulary. w Reference lists linked to Medline abstracts: w The reference lists from each chapter are linked, when available, to their citation on Medline. This page intentionally left blank om.c up ro eg om th.p w w w  ESSENTIALS OF Cardiopulmonary Physical Therapy THIRD EDITION om.c up ro eg ELLEN HILLEGASS, PT, EdD, CCS, FAACVPR om Associate Professor th Department of Physical Therapy.p North Georgia College & State University w Dahlonega, Georgia w w 3251 Riverport Lane St. Louis, Missouri 63043 ESSENTIALS OF CARDIOPULMONARY PHYSICAL THERAPY ISBN: 978-1-437-70381-8 Copyright © 2011, 2001, 1994 by Saunders, an imprint of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice om Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary..c Practitioners and researchers must always rely on their own experience and knowledge in evaluating up and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. ro With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, eg and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each om individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas th contained in the material herein..p ISBN: 978-1-437-70381-8 w w w Executive Editor: Kathy Falk Developmental Editor: Megan Fennell Publishing Services Manager: Julie Eddy Project Manager: Marquita Parker Design Direction: Paula Catalano Working together to grow libraries in developing countries Printed in Canada www.elsevier.com | www.bookaid.org | www.sabre.org Last digit is the print number: 9 8 7 6 5 4 3 2 1  This book is dedicated to my beloved family for all their love and support as well as their understanding during my endless hours of working on this edition: To my husband Dan, who is my rock and my constant support whom I couldn’t live without; To my three wonderful children: Patrick, Jamie and Christi who give me moral support, make me laugh, and who constantly try to keep me up to date on all the modern technologies that have helped me communicate with them, communicate with my colleagues, and write this book. They keep me young with their ideas and assistance; they constantly have a “joie de vivre”; om To my three dogs: Mac, Sparky and Bear who kept my feet warm while I sat for hours at the computer working on this edition but demanded daily play, and provided a wonderful mental.c break from writing; and up To my parents, John and Norma, who keep me busy but are always proud of everything I do. ro eg In addition, I dedicate this edition: om To my colleagues who keep me informed, give me moral and intellectual support and who keep me inspired to maintain my passion for the field of cardiovascular and pulmonary physical th therapy. I especially rely on the support and inspiration of some very dear friends/colleagues.p including Dianne Jewell, Andrew Ries, Claire Rice and Joanne Watchie. w w And finally, I can never forget my very special friends/mentors to whom I am forever grateful and whose memories and teachings are with me always: Michael Pollock (1937–1998), w Linda Crane (1951–1999), and Gary Dudley (1952–2006). This page intentionally left blank om.c up ro eg om th.p w w w  Contributors Tamara L. Burlis, PT, DPT, CCS Anne Mejia Downs, PT, CCS Associate Director of Clinical Education, Assistant Assistant Professor, Krannert School of Physical Therapy, Professor, Program in Physical Therapy and Internal University of Indianapolis, Indianapolis, Indiana Medicine, Washington University, St. Louis, Missouri Physical Therapist, Department of Rehabilitation Services, Clarian Health Partners, Indianapolis, Indiana Lawrence P. Cahalin, PhD, MA Clinical Professor, Department of Physical Therapy Jennifer Edelschick, PT, DPT Northeastern University, Boston, Massachusetts Coordinator of Pediatric Acute PT/OT Services, Physical and Occupational Therapy, Duke Medicine, Durham, Rohini K. Chandrashekar, PT, MS, CCS North Carolina Guest Lecturer, Physical Therapy, Texas Woman’s University, Houston, Texas Susan L. Garritan, PT, PhD, CCS om Physical Therapist, Rehabilitation, Triumph Hospital Clinical Assistant Professor of Rehabilitation Medicine, Clear Lake, Webster, Texas Acute Care Physical Therapy Coordinator, Tisch Hospital,.c New York University Langone Medical Center, New York, Peggy Clough, MA, PT New York Supervisor, Physical Therapy Division, University of Michigan Health System, University Hospital, Ann Arbor, up Kate Grimes, MS, PT, CCS ro Michigan Clinical Assistant Professor, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts eg Meryl Cohen, DPT, MS, CCS Assistant Professor, Department of Physical Therapy, Kristin M. Lefebvre, PT, PhD, CCS om Miller School of Medicine, University of Miami, Assistant Professor, Institute for Physical Therapy Coral Gables, Florida Education, Widener University, Chester Pennsylvania th Adjunct Instructor, Massachusetts General Hospital, Institute of Health Professions, Boston, Massachusetts Ana Lotshaw, PT, PhD, CCS.p Rehabilitation Supervisor, Physical Medicine and w Kelley Crawford, DPT Rehabilitation, Baylor University Medical Center, Level III Clinician, Rehabilitation, Medicine, Dallas, Texas w Maine Medical Center, Portland, Maine w Eugene McColgon, PT Rebecca Crouch, PT, DPT, CCS Program Director, Cardiac Rehabilitation, James A. Haley Adjunct Faculty, Doctoral Program in Physical Therapy, Veterans Hospital, Tampa, Florida Duke University, Durham, North Carolina Coordinator of Pulmonary Rehabilitation, PT/OT, Susan Butler McNamara, MMSc, PT, CCS Duke University Medical Center, Durham, Team Leader, Division of Rehabilitation Medicine, North Carolina Maine Medical Center, Portland, Maine Konrad J. Dias, PT, DPT, CCS Harold Merriman, PT, PhD, CLT Associate Professor, Physical Therapy Program, Maryville Assistant Professor, General Medicine Coordinator, Doctor University, St. Louis, Missouri of Physical Therapy Program, Department of Health and Sports Science, University of Dayton, Dayton, Ohio Christen DiPerna, PT, DPT Physical Therapist, Indiana University Health Methodist Amy Pawlik, PT, DPT, CCS Hospital, Indianapolis, Indiana Program Coordinator, Cardiopulmonary Rehabilitation Therapy Services, The University of Chicago Hospitals, Chicago, Illinois vii viii Contributors Christiane Perme, PT, CCS Debra Seal, PT, DPT Senior Physical Therapist, Physical Therapy and Senior Pediatric Physical Therapist, Acute Therapy, Occupational Therapy Department, The Methodist Cedars-Sinai Medical Center, Los Angeles, California Hospital, Houston, Texas William C. Temes, PT, MS, OCS, FAAOMPT H. Steven Sadowsky, MS, RRT, PT, CCS Director of Interactive Mentorship, Therapeutic Associates, Assistant Professor, Associate Chair for Professional Inc., Eugene, Oregon Education, Department of Physical Therapy and Human Movement Sciences, Northwestern University, Wolfgang Vogel, MS, PhD Chicago, Illinois Professor Emeritus, Department of Pharmacology, Jefferson Medical College, Thomas Jefferson University, Alexandra Sciaky, PT, DPT, MS, CCS Philadelphia, Pennsylvania Adjunct Faculty, Department of Physical Therapy, University of Michigan-Flint, Flint, Michigan Joanne Watchie, MA, PT, CCS Senior Physical Therapist, Coordinator of Clinical Owner, Joanne’s Wellness Ways, Pasadena, California Education, Physical Medicine and Rehabilitation, Physical Therapy Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan om.c up ro eg om th.p w w w  Preface Originally this text was developed to meet the needs of the anatomy was moved to the pediatrics chapter (Chapter 20) physical therapy community, as cardiopulmonary was identi- to help the learner compare the pathophysiology to the fied as one of the four clinical science components in a physi- normal in this population. Chapter 3, Ischemic Cardiovascular cal therapy education program as well as in clinical practice. Conditions and Other Vascular Pathologies, underwent revision Those aspects of physical therapy commonly referred to as as noted by the new title. Material throughout the book was “cardiopulmonary physical therapy” are recognized as funda- reorganized and taken out of some chapters and transferred mental components of the knowledge base and practice base here. New material was added, so that you will now find of all entry-level physical therapists. Although intended pri- hypertension, peripheral arterial disease, cerebrovascular marily for physical therapists, this text has been useful to disease, renal disease and aortic aneurysm is found in this practitioners in various disciplines who teach students or who chapter, in addition to ischemic disease. Chapter 4, Cardiac work with patients who suffer from primary and secondary Muscle Dys­function and Failure, was restructured and revised cardiopulmonary dysfunction. This third edition can also be to improve the flow and understanding of this important om used by all practitioners including those who both teach and pathologic condition. work with patients. Due to the complexities and number of conditions of.c This third edition has gone through major revision. The restrictive lung dysfunction many more tables were created same six sections exist: Anatomy and Physiology; Pathophysio­ in Chapter 5 to separate the material and assist the learner logy; Diagnostic Tests and Procedures; Surgical Interventions, Invasive and Noninvasive Monitoring and Support; Pharmaco­ up to identify key information quickly. Chapter 6, Obstructive Lung Dysfunction, was updated and revised due to the ro logy; and Cardiopulmonary Assessment and Intervention. The increase in the importance of this disease and the fact that six sections were kept as they facilitate the progression of COPD is the fourth leading cause of death. Revisions in eg understanding of the material in order to be able to perform Chapter 7, Cardiopulmonary Implications of Specific Diseases, a thorough assessment and provide an optimal intervention. emphasize information on obesity, diabetes, and metabolic om However, an addition was made to the last section to examine syndrome, as well as cancer and neuromuscular diseases. special population considerations; specifically, pediatric New technologies and advancements in diagnostic tests th cardiopulmonary issues and lymphedema. These are two new and surgical procedures were added to Chapters 8, 9, 10 chapters included to address the great need for this informa- and 11. The advances in transplantation were discussed in.p tion by practitioners and the fact that these are practice Chapter 12 and Invasive and Noninvasive Monitoring and Life w patterns from the Guide that were not covered in any depth Support Equipment (Chapter 13) was revised to increase the in the previous edition. depth of information on ventilators as well as other monitor- w The revisions you should notice include both major and ing equipment. w minor changes. All chapters have been revised as well as As advances in health care and diagnostics occur, so do supplemented with many figures and tables to help the improvements and changes in medications, so both Cardio­ learner visualize the written information. Additional figures, vascular Pharmacology (Chapter 14) and Pulmonary Pharma­ case studies, and resource material can also be found on cology (Chapter 15) required updating and were further the Evolve website which accompanies this text. The number reviewed by a wonderful pharmacist, Dr. Wolfgang Vogel. of clinical notes was increased to help clinicians and stu- Chapter 16 (Examination and Assessment Procedures) had dents understand certain clinical findings and help them some revision, but the chapters following assessment had the relate them to the pathophysiology of cardiovascular and most revision. Acute care, pulmonary rehabilitation and pulmonary disease. All chapters discuss the information in therapeutic interventions all had major updating and revi- each chapter as it relates to the Guide to Physical Therapist sion, new clinical notes and many new figures and tables. Practice and present the practice patterns in tables that are Pediatric Cardiopulmonary Physical Therapy and Lymphedema appropriate for those specific chapters. And, finally, all were two wonderful additions to the third edition of Cardio­ chapters were updated with new information, technology pulmonary Physical Therapy. And, finally, the text ends with and research. the outcomes chapter which was totally revamped and pro- Each chapter had specific revisions that should be high- vides great information for measurement of improvement in lighted. Chapters 1 and 2, which explain anatomy and the cardiopulmonary patient population. physio­logy, went through major revision to help the learner Whenever possible, case studies are provided to exemplify relate the pathophysiology to the normal anatomy and phy­ the material being presented. Additional case studies are siology. In addition, the developmental and maturational found on Evolve. ix x Preface No matter how well you understand the material in this provide the essentials as the title indicates. Learning is a book, it will not make you a master clinician, skilled in continuous process, and technology and treatment are forever the assessment and treatment of cardiovascular and pulmo- improving; therefore, this text provides clinicians as well nary disorders. To become even a minimally competent as educators with the most current information at the time clinician, you will have to practice physical therapy under of publication. the tutelage of an experienced clinician. Essentials of It is my true hope that you appreciate this edition and are Cardiopulmonary Physical Therapy cannot provide you with able to learn from all the wealth of information provided by everything there is to know about the assessment and treat- such wonderful contributors. Without heart and breath there ment of cardiovascular and pulmonary disorders. It will is no therapy! om.c up ro eg om th.p w w w  Acknowledgments “Change is good and change equals opportunity!” This state- wonderful contributors as well as all those clinicians, students ment explains how I have approached each edition, but most and faculty members who provided feedback on previous edi- especially this edition! Hopefully you will gain knowledge tions and who continue to use this book in their courses and and insight from all the changes as there are many excellent their every day practice. I would like to especially thank the contributions from my colleagues, who are THE experts in contributors for their ability to work under my constant cardiovascular and pulmonary physical therapy and who nagging to achieve their deadlines and for providing poured their passion into their chapters. great material including figures, tables and clinical notes. During the publication phase of the first edition of the One special contributor who needs acknowledgement is Dr. Essentials of Cardiopulmonary Physical Therapy I was always Wolfgang Vogel, a pharmacist who reviewed and revised worried about new developments in the field of Cardiovascu- information in the pharmacology chapters to be consistent lar and Pulmonary diagnosis and treatment that were not with the practice of pharmacists. I would also like to acknowl- om going to be covered in the book. My very first editor, Margaret edge and thank Meryl Cohen who kept pressing me to get Biblis kept saying “that’s what the next edition is for” and this edition going as it was her comments that pushed me.c that is how I approached the second edition and again the to finally initiate the third edition. third edition. I have saved comments and suggestions along Of course my family and my dogs need to be acknowledged the way as well as attended conferences regularly to stay current with new developments in the field. And, with the up for all the time I spent at the computer working on this edition instead of spending time with them. ro age of the internet, you will now have access to the new Lastly, this edition truly would not be published were it Evolve site that my wonderful colleague and friend, Dawn not for my wonderful editor, Megan Fennell, who called eg Hayes, has developed to accompany this text. Instructional me weekly and pushed this edition to a timely completion. material including PowerPoint presentations and a test bank She has become a close friend and the best editor ever! om are available to instructors in the course, as well as updated Thanks Megan! information. th So, I would like to thank all the amazing experts who have helped with this third edition, including each of the.p w w w xi This page intentionally left blank om.c up ro eg om th.p w w w  Contents Section 1 Anatomy and Physiology Section 4 Surgical Interventions, Monitoring, and Support Ch01 Anatomy of the Cardiovascular and Pulmonary Systems 1 Ch11 Cardiovascular and Thoracic Konrad Dias Interventions 389 Ch02 Physiology of the Cardiovascular and Ellen Hillegass Pulmonary Systems 27 H. Steven Sadowsky Konrad Dias Ch12 Thoracic Organ Transplantation: Heart, Heart-Lung, and Lung 410 Tamara Versluis Burlis om Section 2 Pathophysiology Anne Mejia Downs Christen DiPerna.c Ch03 Ischemic Cardiovascular Conditions Ch13 Monitoring and Life Support and Other Vascular Pathologies 47 Equipment 442 Ellen Hillegass Joanne Watchie up Rohini Chandrashekar Christiane Perme ro Eugene McColgon eg Ch04 Cardiac Muscle Dysfunction and Failure 84 Section 5 Pharmacology om Ellen Hillegass Lawrence Cahalin Ch14 Cardiovascular Medications 465 Ch05 Restrictive Lung Dysfunction 136 Meryl Cohen th Ellen Hillegass Kate Grimes Wolfgang Vogel.p Peggy Clough Ch06 Chronic Obstructive Pulmonary Ch15 Pulmonary Medications 515 w Diseases 201 Kelley Crawford w Susan Garritan Susan Butler McNamara Wolfgang Vogel w Ch07 Cardiopulmonary Implications of H. Steven Sadowsky Specific Diseases 228 Joanne Watchie Section 6 Cardiopulmonary Assessment and Intervention Section 3 Diagnostic Tests and Procedures Ch16 Examination and Assessment Procedures 534 Ch08 Cardiovascular Diagnostic Tests and Ellen Hillegass Procedures 288 Ch17 Interventions for Acute Ellen Hillegass Cardiopulmonary Conditions 568 Ch09 Electrocardiography 331 Alexandra Sciaky Ellen Hillegass Amy Pawlik Ch10 Pulmonary Diagnostic Tests and Ch18 Interventions and Prevention Measures Procedures 365 for Individuals with Cardiovascular Ana Lotshaw Disease, or Risk of Disease 598 H. Steven Sadowsky Ellen Hillegass Ellen Hillegass William Temes xiii xiv Contents Ch19 Pulmonary Rehabilitation 638 Ch21 The Lymphatic System 682 Rebecca Crouch Harold Merriman Ch20 Pediatric Cardiopulmonary Physical Ch22 Outcome Measures: A Guide for Therapy 659 the Evidence-Based Practice of Jennifer Edelschick Cardiopulmonary Physical Therapy 708 Debra Seal Kristin Lefebvre om.c up ro eg om th.p w w w CHAPTER 1 Anatomy of the Cardiovascular and Pulmonary Systems Konrad Dias Chapter Outline Thorax Left Coronary Artery Sternum Pulmonary Artery Ribs Pulmonary Veins The Respiratory System Vena Cava and Cardiac Veins Muscles of Ventilation Systemic Circulation Muscles of Expiration Arteries Pulmonary Ventilation Endothelium The Cardiovascular System Veins Mediastinum Summary om Heart References Innervation.c Cardiac and Pulmonary Vessels Aorta Right Coronary Artery up ro eg om This chapter describes the anatomy of the cardiovascular and Sternum th pulmonary systems as it is relevant to the physical therapist. Knowledge of the anatomy of these systems provides clini- The sternum or breastbone is a flat bone with three major.p cians with the foundation to perform the appropriate exami- parts: manubrium, body, and xiphoid process (see Fig. 1-1). w nation and provide optimal treatment interventions for Superiorly located within the sternum, the manubrium is individuals with cardiopulmonary dysfunction. An effective the thickest component articulating with the clavicles, first w understanding of cardiovascular and pulmonary anatomy and second ribs. A palpable jugular notch or suprasternal w allows for comprehension of function and an appreciation of notch is found at the superior border of the manubrium the central components of oxygen and nutrient transport to of the sternum. Inferior to the manubrium lies the body of peripheral tissue. A fundamental assumption is made; namely, the sternum articulating laterally with ribs three to seven. that the reader already possesses some knowledge of anatomi- The sternal angle or “angle of Louis” is the anterior angle cal terms and cardiopulmonary anatomy. formed by the junction of the manubrium and the body of the sternum. This easily palpated structure is in level with the second costal cartilage anteriorly and thoracic vertebrae Thorax T4 and T5 posteriorly. The most caudal aspect of the sternum is the xiphoid process, a plate of hyaline cartilage that ossifies The bony thorax covers and protects the major organs of the later in life. cardiopulmonary system. Within the thoracic cavity exist the The sternal angle marks the level of bifurcation of the heart, housed within the mediastinum centrally, while later- trachea into the right and left main stem bronchi as well as ally are two lungs. The bony thorax provides a skeletal frame- provides for the pump handle action of the sternal body work for the attachment of the muscles of ventilation. during inspiration.1 The thoracic cage (Fig. 1-1) is conical at both its superior Pectus excavatum is a common congenital deformity of and inferior aspects and somewhat kidney-shaped in its trans- the anterior wall of the chest, in which several ribs and the verse aspect. The skeletal boundaries of the thorax are the 12 sternum grow abnormally (see Fig. 5-19). This produces a thoracic vertebrae dorsally, the ribs laterally, and the sternum caved-in or sunken appearance of the chest. It is present at ventrally. birth but rapidly progresses during the years of bone growth 1 2 SECTION 1 Anatomy and Physiology Clavicle Scapula 1 2 Manubrium 3 Body or gladiolus 4 Sternum 5 6 Xiphoid process 7 Costal cartilage 8 9 10 A 11 om Cervical vertebra 7.c 1 Clavicle 2 Thoracic vertebra 1 up 3 4 Scapula 5 ro 6 7 eg 8 9 om 10 11 12 Thoracic vertebra 12 th Lumbar vertebra 1.p B w Figure 1-1 A, Anterior. B, Posterior views of the bones of the thorax. (From Hicks GH. Cardiopulmonary Anatomy and Physiology. Philadelphia, 2000, Saunders.) w w in the early teenage years. These patients have several pul- (also known as the vertebrosternal ribs); the lower five ribs monary complications including shortness of breath caused are termed the false ribs—the eight, ninth, and tenth ribs by altered mechanics of the inspiratory muscles on the attach to the rib above by their costal cartilages (the verte- caved-in sternum and ribs, and often have cardiac complica- brochondral ribs), and the eleventh and twelfth ribs end tions caused by the restriction (compression) of the heart.2 freely (the vertebral ribs see Fig. 1-1). The true ribs increase To gain access to the thoracic cavity for surgery, including in length from above downward, while the false ribs decrease coronary artery bypass grafting, the sternum is spit in the in length from above downward. median plane and retracted. This procedure is known as a Each rib typically has a vertebral end separated from a median sternotomy. Flexibility of the ribs and cartilage allow sternal end by the body or shaft of the rib. The head of the for separation of the two ends of the sternum to expose the rib (at its vertebral end) is distinguished by a twin-faceted thoracic cavity.3 surface for articulation with the facets on the bodies of two adjacent thoracic vertebrae. The cranial facet is smaller than the caudal, and a crest between these permits attachment of Ribs the interarticular ligament. The ribs, although considered “flat” bones, curve forward and Figure 1-2 displays the components of typical ribs three to downward from their posterior vertebral attachments toward nine, each with common characteristics including a head, their costal cartilages. The first seven ribs attach via their neck, tubercle, and body. The neck is the 1-inch long portion costal cartilages to the sternum and are called the true ribs of the rib extending laterally from the head; it provides  C H A P T E R 1 Anatomy of the Cardiovascular and Pulmonary Systems 3 Head Articular facet for transverse process Superior Vertebral Neck articular Inferior facets Tubercle Costal groove Figure 1-2 Typical middle rib as viewed from the posterior. The head end articulates with the vertebral bones and the distal end is attached to the costal cartilage of the sternum. (From Wilkins RL. Egan’s Fundamentals of Respiratory Care ed 9. St. Louis, 2009, Mosby.) om attachment for the anterior costotransverse ligament along space between the inner lining and the outer lining of the.c its cranial border. The tubercle at the junction of the neck lung (pleural space). and the body of the rib consists of an articular and a non­ The first, second, tenth, eleventh, and twelfth ribs are articular portion. The articular part of the tubercle (the more medial and inferior of the two) has a facet for articulation up unlike the other, more typical ribs (Fig. 1-3). The first rib is the shortest and most curved of all the ribs. Its head is small ro with the transverse process of the inferior most vertebra to and rounded and has only one facet for articulation with the which the head is connected. The nonarticular part of body of the first thoracic vertebra. The sternal end of the first eg the tubercle provides attachment for the ligament of the rib is larger and thicker than it is in any of the other ribs. tubercle. The second rib, although longer than the first, is similarly om The shaft or body of the rib is simultaneously bent in two curved. The body is not twisted. There is a short costal groove directions and twisted about its long axis, presenting two on its internal surface posteriorly. The tenth through twelfth th surfaces (internal and external) and two borders (superior and ribs each have only one articular facet on their heads. The inferior). A costal groove, for the intercostal vessels and eleventh and twelfth ribs (floating ribs) have no necks or.p nerve, extends along the inferior border dorsally but changes tubercles and are narrowed at their free anterior ends. The w to the internal surface at the angle of the rib. The sternal end twelfth rib sometimes is shorter than the first rib. of the rib terminates in an oval depression into which the w costal cartilage makes its attachment. w Although rib fractures may occur in various locations, they The Respiratory System are more common in the weakest area where the shaft of the ribs bend—the area just anterior to its angle. The first rib The respiratory system includes the bony thorax, the muscles does not usually fracture as it is protected posteroinferiorly by of ventilation, the upper and the lower airways, and the the clavicle. When it is injured, the brachial plexus of nerves pulmonary circulation. The many functions of the respiratory and subclavian vessel injury may occur.4 Lower rib fractures system include gas exchange, fluid exchange, maintenance of may cause trauma to the diaphragm resulting in a diaphrag- a relatively low-volume blood reservoir, filtration, and meta­ matic hernia. Rib fractures are extremely painful because of bolism, and they necessitate an intimate and exquisite inter- their profound nerve supply. It is important for all therapists action of these various components. Because the thorax has to recommend breathing, splinting and coughing strategies already been discussed, this section deals with the muscles of for patients with rib fractures. Paradoxical breathing patterns ventilation, the upper and lower airways, and the pulmonary and a flail chest may also need to be evaluated in light of circulation. multiple rib fractures in adjacent ribs.3 Chest tubes are inserted above the ribs to avoid trauma to Muscles of Ventilation vessels and nerves found within the costal grove. A chest tube insertion involves the surgical placement of a hollow, flexible Ventilation or breathing involves the processes of inspiration drainage tube into the chest. This tube is used to drain blood, and expiration. For air to enter the lungs during inspiration, air, or fluid around the lungs and effectively allow the lung muscles of the thoracic cage and abdomen must move the to expand. The tube is placed between the ribs and into the bony thorax to create changes in volume within the thorax 4 SECTION 1 Anatomy and Physiology Tubercle Head Attachment for scalene medius Neck Body Scalene tubercle Articulation with first costal cartilage Groove for subclavian v om Figure 1-3 Superior view of the first right rib. (From Liebgott B. The Anatomical Basis of Dentistry ed 2. St. Louis, 2002, Mosby.).c A INSPIRATION B BUCKET-HANDLE AND WATER-PUMP– up C EXPIRATION ro External intercostal muscles slope obliquely HANDLE EFFECTS between ribs, forward and downward. Because Internal intercostal muscles slope the attachment to the lower rib is farther obliquely between ribs, backward eg forward from the axis of rotation, contraction Vertebra and downward, depressing the raises the lower rib more than it depresses the upper rib more than raising the om upper rib. lower rib. Scalene Sternocleidomastoid muscles muscle Vertebra th Sternum Ribs.p Sternum w w w Diaphragm Rectus External abdominis oblique muscle muscle Figure 1-4 Actions of major respiratory muscles. (From Boron WF. Medical Physiology. Updated Edition. St. Louis, 2005, Saunders.) and cause a concomitant reduction in the intrathoracic pres- atmospheric pressure, forcing air into the lungs to help nor- sure. Inspiratory muscles increase the volume of the thoracic malize pressure differences. The essential muscles to achieve cavity by producing bucket handle and pump handle move- the active process of inspiration at rest are the diaphragm ments of the ribs and sternum depicted in Figure 1-4. The and internal intercostals. To create a more forceful inspira- resultant reduced intrathoracic pressure generated is below tion during exercise or cardiopulmonary distress, accessory  C H A P T E R 1 Anatomy of the Cardiovascular and Pulmonary Systems 5 Phrenic nerves Right lung Left lung Central tendon Left hemidiaphragm Esophagus Inferior vena cava Right hemidiaphragm Lumbar vertebra 2 om Xiphoid process.c Inferior vena cava up ro Right hemidiaphragm Left hemidiaphragm eg Esophagus om Central tendon th Abdominal aorta.p w Abdominal wall w Figure 1-5 The diaphragm originates from lumbar vertebra, lower ribs, xiphoid process, and abdominal wall and converges in a w central tendon. Note the locations of the phrenic nerves and openings for the inferior vena cava, esophagus, and abdominal aorta. (From Hicks GH. Cardiopulmonary Anatomy and Physiology. Philadelphia, 2000, Saunders.) muscles assist with the inspiration. The accessory muscles Each hemidiaphragm is composed of three musculoskeletal include the sternocleidomastoid, scalenes, serratus anterior, components, including the sternal, costal, and lumbar por- pectoralis major and minor, trapezius, and erector spinae tions that converge into the central tendon. The central muscles. tendon of the diaphragm is a thin but strong layer of tendons (aponeurosis) situated anteriorly and immediately below the Diaphragm pericardium. There are three major openings to enable The diaphragm is the major muscle of inspiration. It is a various vessels to traverse the diaphragm. These include the musculotendinous dome that forms the floor of the thorax vena caval opening for the inferior vena cava, the esophageal and separates the thoracic and abdominal cavities (Fig. 1-5). opening for the esophagus and gastric vessels and the aortic The diaphragm is divided into right and left hemidiaphragms. opening containing the aorta, thoracic duct and azygous Both hemidiaphragms are visible on radiographic studies veins. The phrenic nerve arises from the third, fourth, and from the front or back. The right hemidiaphragm is protected fifth cervical spinal nerves (C3 to C5) and is involved in by the liver and is stronger than the left. The left hemidia- contraction of the diaphragm. phragm is more often subject to rupture and hernia, usually The resting position of the diaphragm is an arched posi- because of weaknesses at the points of embryologic fusion. tion high in the thorax. The level of the diaphragm and the 6 SECTION 1 Anatomy and Physiology amount of movement during inspiration vary as a result of factors such as body position, obesity, and size of various gastrointestinal organs present below the diaphragm. During normal ventilation or breathing, the diaphragm contracts to pull the central tendon down and forward. In doing so, the External intercostal resting dome shape of the diaphragm is reversed to a flatting of the diaphragm. Contraction of this muscle increases the dimensions of the thorax in a cephalocaudal, anterior poste- Internal intercostal rior, and lateral direction.1 The increase in volume decreases pressure in the thoracic cavity and simultaneously causes a decrease in volume and an increase in pressure within the abdominal cavity. The domed shape of the diaphragm is largely maintained until the abdominal muscles end their extensibility, halting the downward displacement of the abdominal viscera, essentially forming a fixed platform Figure 1-6 The external intercostal muscles lift the inferior beneath the central tendon. The central tendon then ribs and enlarge the thoracic cavity. The internal intercostal becomes a fixed point against which the muscular fibers of muscles compresses the thoracic cavity by pulling together the the diaphragm contract to elevate the lower ribs and thereby ribs. (From Hicks GH. Cardiopulmonary Anatomy and Physio­ logy. Philadelphia, 2000, Saunders.) push the sternum and upper ribs forward. The right hemidia- phragm meets more resistance than the left (because the liver om underlies the right hemidiaphragm; the stomach underlies the left) during its descent; it is therefore more substantial of an inch; with maximal ventilatory effort the diaphragm.c than the left. may move from 2.5 to 4 inches.5 In patients with chronic obstructive pulmonary disease there is compromised ability to expire. This results in a flat- tening of the diaphragm as a result of the presence of hyper- up External Intercostal Muscles The external intercostal muscles originate from the lower ro inflated lungs.1,5 It is essential for therapists to reverse borders of the ribs and attach to the upper border of the ribs hyperinflation and restore the normal resting arched position below (Fig. 1-6). There are 11 external intercostal muscles eg of the diaphragm prior to any using any exercise aimed at on each side of the sternum. Contraction of these muscles strengthening the diaphragm muscle. A flat and rigid dia- pull the lower rib up and out toward the upper rib thereby om phragm cannot be strengthened and will cause an automatic elevating the ribs and expanding the chest. firing of the accessory muscles to trigger inspiration. th Body position in supine, upright or side lying alters the Accessory Muscles resting position of the diaphragm, resulting in concomitant Figure 1-7 explains the anatomy of the accessory muscles..p changes in lung volumes.6 In the supine position, without the w effects of gravity, the level of the diaphragm in the thoracic Sternocleidomastoid Muscle cavity rises. This allows for a relatively greater excursion of The sternocleidomastoid arises by two heads (sternal and w the diaphragm. Despite a greater range of movement of the clavicular, from the medial part of the clavicle), which unite w diaphragm, lung volumes are low as a consequence of the to extend obliquely upward and laterally across the neck to elevated position of the abdominal organs within the thoracic the mastoid process. For this muscle to facilitate inspiration, cavity. In an upright position, the dome of the diaphragm is the head and neck must be held stable by the neck flexors pulled down because of the effects of gravity. The respiratory and extensors. This muscle is a primary accessory muscle excursion is less in this position; however, the lung volumes and elevates the sternum, increasing the anterior-posterior are larger. In the side-lying position, the hemidiaphragms are diameter of the chest. unequal in their positions: The uppermost side drops to a lower level and has less excursion than that in the sitting Scalene Muscle position; the lowermost side rises higher in the thorax and The scalene muscles lie deep to the sternocleidomastoid, but has a greater excursion than in the sitting position. In quiet may be palpated in the posterior triangle of the neck. These breathing, the diaphragm normally moves about two-thirds muscles function as a unit to elevate and fix the first and second ribs. The anterior scalene muscle passes from the anterior tubercles of the transverse processes of the third or Clinical Tip fourth to the sixth cervical vertebrae, attaching by Stomach fullness, obesity with presence of a large pannus, ascites tendinous insertion into the first rib. with increased fluid in the peritoneal space from liver disease, and The middle scalene muscle arises from the transverse pregnancy are additional factors affecting the normal excursion of processes of all the cervical vertebrae to insert onto the diaphragm during inspiration. the first rib (posteromedially to the anterior scalene  C H A P T E R 1 Anatomy of the Cardiovascular and Pulmonary Systems 7 Trapezius muscle 7th cervical spinous process Rhomboideus minor muscle Rhomboideus major muscle Transverse process Sympathetic trunk Scapula Infraspinatus muscle Greater splanchic nerve branches Teres minor muscle Teres major muscle Vertebral spine Esophagus Internal intercostal muscle Intertransverse Latissimus muscle dorsi muscle Parietal plura Intercostal artery Interior membrane Spinal branch External intercostal muscle 12th thoracic Transversus muscle spinous process Serratus posterior om Intercostal inferior muscle vein-artery-nerve (ventral) Transversalis fascia Internal oblique muscle.c Lumbocostal ligaments Quadratus lumborum muscle up Dorsal branch External oblique muscle Cutaneous nerve branch Anterior lumbar fascia ro Erector spinae muscle Posterior lumbar fascia eg om Figure 1-7 Musculature of the chest wall. (From Ravitch MM, Steichen FM. Atlas of General Thoracic Surgery. Philadelphia, 1988, Saunders.) th the brachial plexus and subclavian artery pass between insertion as its origin and pull on the anterior chest wall,.p anterior scalene and middle scalene). lifting the ribs and sternum and facilitate an increase in the w The posterior scalene muscle arises from the posterior anteroposterior diameter of the thorax. tubercles of the transverse processes of the fifth and The pectoralis minor arises from the second to fifth or the w sixth cervical vertebrae, passing between the middle third to sixth ribs upward to insert into the medial side of the w scalene and levator scapulae, to attach onto the coracoid process close to the tip. This muscle assists in forced second or third rib. inspiration by raising the ribs and increasing intrathoracic volume. Upper Trapezius The trapezius (upper fibers) muscle arises from the medial Serratus Anterior and Rhomboids part of the superior nuchal line on the occiput and the The serratus anterior arises from the outer surfaces of the ligamentum nuchae (from the vertebral spinous processes upper eight or nine ribs to attach along the costal aspect of between the skull and the seventh cervical vertebra) to insert the medial border of the scapula. The primary action of the onto the distal third of the clavicle. This muscle assists with serratus is to abduct, rotate the scapula, and hold the medial ventilation by helping to elevate the thoracic cage. border firmly over the rib cage. The serratus can only be utilized as an accessory muscle in ventilation, when the Pectoralis Major and Minor rhomboids stabilize the scapula in adduction.7 The action of The pectoralis major arises from the medial third of the the rhomboids fixes the insertion, allowing the serratus to clavicle, from the lateral part of the anterior surface of the expand the rib cage by pulling the origin toward the manubrium and body of the sternum, and from the costal insertion. cartilages of the first six ribs to insert upon the lateral lip of the crest of the greater tubercle of the humerus. When the Latissimus Dorsi arms and shoulders are fixed, by leaning on the elbows or The latissimus dorsi arises from the spinous processes of the grasping onto a table, the pectoralis major can use its lower six thoracic, the lumbar, and the upper sacral vertebrae, 8 SECTION 1 Anatomy and Physiology from the posterior aspect of the iliac crest, and slips from the the dimensions of the thoracic cavity and concomitantly lower three or four ribs to attach to the intertubercular groove reduce the pressure in the lungs (intrathoracic pressure) of the humerus.7 The posterior fibers of this muscle assist in below the air pressure outside the body. With the respiratory inspiration as they pull the trunk into extension. tract being open to the atmosphere, air rushes into the lungs to normalize the pressure difference, allowing inspiration to Serratus Posterior Superior occur and the lungs to fill with air. The serratus posterior superior passes from the lower part of During forced or labored breathing, additional accessory the ligamentum nuchae and the spinous processes of the muscles need to be used to increase the inspiratory maneu- seventh cervical and first two or three thoracic vertebrae ver. The accessory muscles raise the ribs to a greater extent downward into the upper borders of the second to fourth or and promote extension of the thoracic spine. These changes fifth ribs. This muscle assists in inspiration by raising the ribs facilitate a further increase in the volume within the tho- to which it is attached and expanding the chest. racic cavity and a subsequent drop in the intrathoracic pressure beyond that caused by the contraction of the Thoracic Erector Spinae Muscles diaphragm and external intercostals. This relatively lower The erector spinae is a large muscle group extending from the intrathoracic pressure will promote a larger volume of air sacrum to the skull. The thoracic erector spinae muscles entering the lung. extend the thoracic spine and raise the rib cage to allow At rest, expiration is a passive process and achieved greater expansion of the thorax. through the elastic recoil of the lung and relaxation of the external intercostal and diaphragm muscle. As the external intercostals relax, the rib drops to its preinspiratory position om Muscles of Expiration and the diaphragm returns to its elevated dome position high Abdominal Muscles in the thorax. To achieve a forceful expiration additional.c The abdominal muscles include the rectus abdominis, trans- muscle can be used, including the abdominals and internal versus abdominis, and internal and external obliques. These intercostal muscles. The internal intercostals actively pull the muscles work to raise intraabdominal pressure when a sudden expulsion of air is required in maneuvers such as huffing and up ribs down to help expel air out of the lungs. The abdominals contract to force the viscera upward against the diaphragm, ro coughing. Pressure generated within the abdominal cavity accelerating its return to the dome position. is transmitted to the thoracic cage to assist in emptying eg the lungs. om Clinical Tip Internal Intercostal Muscles The changes in intraabdominal and intrathoracic pressure that occur Eleven internal intercostal muscles exist on each side of the with forced breathing assist with venous return of blood back to the th sternum. These muscles arise on the inner surfaces of the ribs heart. The drop in pressure allows for a filling of the veins, while the and costal cartilages and insert on the upper borders of the changing pressure within the abdomen and thorax cause a milking.p adjacent ribs below (see Fig. 1-6). The posterior aspect on effect to help return blood back to the heart. w the internal intercostal muscles is termed the interosseus portion and depresses the ribs to aid in a forceful expiration. w The intercartilaginous portion of the internal intercostals Pleurae w elevates the ribs and assists in inspiration. Two serous membranes or pleurae exist that cover each lung (Fig. 1-8). The pleura covering the outer surface of each lung is the visceral pleura and is inseparable from the tissue Pulmonary Ventilation of the lung. The pleura covering the inner surface of the Pulmonary ventilation, commonly referred to as breathing, is chest wall, diaphragm and mediastinum is called the parietal the process in which air is moved in and out of the lungs. pleura. The parietal pleura is frequently described with Inspiration, an active process at rest and during exercise, reference to the anatomic surfaces it covers: the portion involves contraction of the diaphragm and external intercos- lining the ribs and vertebrae is named the costovertebral tal muscles. The muscle that contracts first is the diaphragm, pleura; the portion over the diaphragm is the diaphragmatic with a caudal movement and resultant increase within the pleura; the portion covering the uppermost aspect of the volume of the thoracic cavity. The diaphragm eventually lung in the neck is the cervical pleura; and that overlying meets resistance against the abdominal viscera causing the the mediastinum is called the mediastinal pleura.8 Parietal costal fibers of the diaphragm to contract and pull the lower and visceral pleurae blend with one another where they ribs up and out—the bucket handle movement. The outward come together to enclose the root of the lung. Normally the movement is also facilitated by the external intercostal pleurae are in intimate contact during all phases of the ven- muscles. In addition, a pump handle movement of the upper tilatory cycle, being separated only by a thin serous film. ribs is achieved through contraction of the external intercos- There exists a potential space between the pleurae called tals and the intercartilaginous portion of the internal inter- the pleural space or pleural cavity. A constant negative pres- costal muscles. The actions of the inspiratory muscles expand sure within this space maintains lung inflation. The serous  C H A P T E R 1 Anatomy of the Cardiovascular and Pulmonary Systems 9 a collapsed lung is termed a pneumothorax. Finally, a bacte- C rial infection with resultant pus in the pleural space is referred to as empyema. Management for several of these complications of the D pleural space is achieved through insertion of a chest tube into the pleural space to drain pleural secretions or to restore B a negative pressure within the space and allow for lung infla- tion. A needle aspiration of fluid from the space, a thoraco- H centesis, may be performed for patients with large pleural effusions. A Lungs The lungs are located on either side of the thoracic cavity, separated by the mediastinum. Each lung lies freely within its corresponding pleural cavity, except where it is attached to the heart and trachea by the root and pulmonary ligament. The substance of the lung—the parenchyma—is normally porous and spongy in nature. The surfaces of the lungs are marked by numerous intersecting lines that indicate the poly- G E hedral (secondary) lobules of the lung. The lungs are basically om cone shaped and are described as having an apex, a base, F three borders (anterior, inferior, posterior), and three surfaces.c Figure 1-8 Pleurae of the lungs. A, Pleural space. B, Visceral (costal, medial, and diaphragmatic). pleura. C, Cervical parietal pleura. D, Costal parietal pleura. The apex of each lung is situated in the root of the neck, E, Mediastinal parietal pleura. F, Diaphragmatic parietal pleura. G, Costodiaphragmatic recess. H, Parietal pleura. (From up its highest point being approximately 1 inch above the middle third of each clavicle. The base of each lung is concave, ro Applegate E. The Sectional Anatomy Learning System: Concepts/Applications ed 3. St. Louis, 2010, Saunders.) resting on the convex surface of the diaphragm. The inferior border of the lung separates the base of the lung from its eg costal surface; the posterior border separates the costal surface fluid within the pleural space serves to hold the pleural layers from the vertebral aspect of the mediastinal surface; the ante- om together during ventilation and reduce friction between the rior border of each lung is thin and overlaps the front of the lungs and the thoracic wall.6,8 pericardium. Additionally, the anterior border of the left lung th The parietal pleura receives its vascular supply from the presents a cardiac notch. The costal surface of each lung intercostal, internal thoracic, and musculophrenic arteries. conforms to the shape of the overlying chest wall. The medial.p Venous drainage is accomplished by way of the systemic veins surface of each lung may be divided into vertebral and medi- w in the adjacent parts of the chest wall. The bronchial vessels astinal aspects. The vertebral aspect contacts the respective supply the visceral pleura. There exists no innervation to the sides of the thoracic vertebrae and their intervertebral disks, w visceral pleura and therefore no sensation.5 The phrenic the posterior intercostal vessels, and nerves. The mediastinal w nerve innervates the parietal pleura of the mediastinum and aspect is notable for the cardiac impression; this concavity is central diaphragm, whereas the intercostal nerves innervate larger on the left than on the right lung to accommodate the the parietal pleura of the costal region and peripheral projection of the apex of the heart toward the left. Just pos- diaphragm. terior to the cardiac impression is the hilus, where the struc- Irritation of the intercostally innervated pleura may result tures forming the root of the lung enter and exit the in the referral of pain to the thoracic or abdominal walls, and parenchyma. The extension of the pleural covering below irritation of the phrenic supplied pleura can result in referred and behind the hilus from the root of the lung forms the pain in the lower neck and shoulder.9 pulmonary ligament. Several complications can affect pleural integrity. Infec- tion with resultant inflammatory response within the pleura Hila and Roots is termed pleuritis or pleurisy and is best appreciated through The point at which the nerves, vessels, and primary bronchi the presence of pleural chest pain, and an abnormal pleural penetrate the parenchyma of each lung is called the hilus. friction rub on auscultation.9 A pleural effusion refers to a The structures entering the hila of the lungs and forming the buildup of fluid in the pleural space commonly seen following roots of each of the lungs are the principal bronchus, the cardiothoracic surgery or with cancer. This is evidenced by pulmonary artery, the pulmonary veins, the bronchial arteries diminished or absent breath sounds in the area of the effu- and veins, the pulmonary nerve plexus, and the lymph vessels sion, more likely to be in gravity dependant areas and accom- (Fig. 1-9). They lie next to the vertebral bodies of the fifth, panied by reduced lung volumes. Blood in the pleural space sixth, and seventh thoracic vertebrae. The right root lies is termed a hemothorax, whereas air in the pleural space from behind the superior vena cava and a portion of the right 10 SECTION 1 Anatomy and Physiology Apex Oblique fissure Upper lobe Upper lobe Pulmonary arteries Bronchus Pulmonary Horizontal fissure veins Hilum Posterior Hilum border Cardiac Oblique fissure notch Lower Middle lobe lobe Inferior border Inferior border Base Right lung Left lung Figure 1-9 The medial surfaces of the lungs. (From Hicks GH. Cardiopulmonary Anatomy and Physiology. Philadelphia, 2000, Saunders.) om ANTERIOR POSTERIOR.c up Parietal pleura Visceral ro pleura Parietal 1 Major eg pleura Major Minor (oblique) (horizontal) (oblique) 2 RUL LUL Visceral LUL RUL fissure of fissure fissure of 3 right lung om pleura left lung 4 5 LLL RLL th 6 Outline RML of heart Major 7.p (oblique) 8 fissure of Major 9 RLL (oblique) w right lung LLL Level of 6th rib fissure of 10 left lung w 11 Right dome of diaphragm 12 w (level of 5th rib) Right dome A Level of 9th rib B of diaphragm Figure 1-10 Anterior (A) and posterior (B) views of the fissures of the lungs and the extent of the parietal pleura. (Redrawn from Kersten LD. Comprehensive Respiratory Nursing: A Decision Making Approach. Philadelphia, 1989, Saunders.) atrium, below the end of the azygos vein; the left root lies (see Fig. 1-9 and Fig. 1-10). Starting on the medial surface of below the arch of the aorta and in front of the descending the right lung at the upper posterior aspect of the hilus, the thoracic aorta. The pulmonary ligament lies below the root; oblique fissure runs upward and backward to the posterior the phrenic nerve and the anterior pulmonary plexus lie in border at about the level of the fourth thoracic vertebra; it front of the root; the vagus nerve and posterior pulmonary then descends anteroinferiorly across the anterior costal plexus lie behind the root. surface to intersect the lower border of the lung approxi- mately 5 inches from the median plane, and then passes Lobes, Fissures, and Segments posterosuperiorly to rejoin the hilus just behind and beneath The right lung consists of three lobes including the right the upper pulmonary vein. The RML is separated from the upper lobe (RUL), right middle lobe (RML), and right lower RUL by the horizontal (minor) fissure that joins the oblique lobe (RLL). Two fissures separate these three lobes from one fissure at the midaxillary line at about the level of the fourth another. The upper and middle lobes of the right lung are rib and runs horizontally across the costal surface of the lung separated from the lower lobe by the oblique (major) fissure to about the level of the fourth costal cartilage; on the medial  C H A P T E R 1 Anatomy of the Cardiovascular and Pulmonary Systems 11 surface, it passes backward to join the hilus near the upper environment, the nasal cavity blends posteriorly with the right pulmonary vein. nasopharynx. The two halves are essentially identical, having Each lobe of the right lung is further subdivided into seg- a floor, medial and lateral walls, and a roof divided into three ments. The RUL has three segments, including the apical, regions: the vestibule, the olfactory region, and the respira- posterior, and anterior segments. This lobe extends to the tory region. level of the fourth rib anteriorly, and is adjacent to ribs three The primary respiratory functions of the nasal cavity to five posteriorly. The RML is subdivided into the lateral include air conduction, filtration, humidification, and tem- and medial lobes. This lobe is the smallest of the three lobes. perature control; it also plays a role in the olfactory process. Its inferior border is adjacent to the fifth rib laterally and sixth Three nasal conchae project into the nasal cavity from the rib medially. The lowermost lobe, the RLL consist of four lateral wall toward the medial wall; they are named the supe- segments (anterior basal, superior basal, lateral basal, and rior, middle, and inferior conchae. The conchae serve to posterior basal). The superior border of the RLL is at the level increase the respiratory surface area of the nasal mucous of the sixth thoracic vertebrae and extends inferiorly down membrane for greater contact with inspired air. The vestibule to the diaphragm. During maximal inspiration, the inferior of the nasal cavity is lined with skin containing many coarse border of the RLL may extend to the second lumbar vertebrae hairs and sebaceous and sweat glands. Mucous membrane and superimpose over the superior aspects of the kidney. lines the remainder of the nasal cavity. Figure 1-12 depicts The left lung is relatively smaller than the right lung and examples of some selected types of mucosal coverings in the has only two lobes including the left upper lobe (LUL) and upper and lower respiratory tracts. left lower lobe (LLL). The left lung is divided into upper The olfactory region of the nasal cavity is distinguished by and lower lobes by the oblique fissure, which is somewhat specialized mucosa. This pseudostratified olfactory epithelium om more vertically oriented than that of the right lung; there is is composed of ciliated receptor cells, nonciliated sustentacu- no horizontal fissure. The portion of the left lung that cor- lar cells, and basal cells that help to provide a sense of smell.8.c responds to the right lung is termed the lingular segment and Sniffing increases the volume of inspired air entering the is a part of the LUL. Posteriorly, the inferior border of the olfactory region, allowing the individual to smell something LUL is at the level of the sixth rib, while the LLL is at the level of the eleventh rib. up specific.4