Respiratory Module 1 Part 3 PDF

RESPIRATORY MODULE 1 PART 3 ANATOMY AND PHYSIOLOGY COLLEEN DANIELS MS,CRNA  ALVEOLAR EPITHELIUM TYPE I PNEUMOCYTES TYPE II PNEUMOCYTES MACROPHAGES MAST CELLS LYMPHOCYTES APUD (AMINO PRECURSOR UPTAKE AND DECARBOXYLATION) (HORMONE SECRETING) NEUTRO...

RESPIRATORY MODULE 1 PART 3 ANATOMY AND PHYSIOLOGY COLLEEN DANIELS MS,CRNA  ALVEOLAR EPITHELIUM TYPE I PNEUMOCYTES TYPE II PNEUMOCYTES MACROPHAGES MAST CELLS LYMPHOCYTES APUD (AMINO PRECURSOR UPTAKE AND DECARBOXYLATION) (HORMONE SECRETING) NEUTROPHILS (SMOKERS AND ACUTE LUNG INJURY)  PORES OF KOHN (COLLATERAL VENTILATION) AIRWAYS < 1MM DIAMETER SUSCEPTIBLE TO BLOCKAGE  ACCUMULATION OF FLUID, SECRETIONS & INHIBIT GAS O2 TRANSPORT SMALL HOLES IN THE WALLS OF INTERALVEOLAR SEPTA ALLOW GAS MOVEMENT TO ADJACENT ALVEOLI FORMATION OF PORES MAY INCLUDE ONE OR MORE OF FOLLOWING PROCESSES DESQUAMATION (SHEDDING OR PEELING) OF EPITHELIAL CELLS DUE TO DISEASE NORMAL GENERATION OF TISSUE CELLS DUE TO AGE MOVEMENT OF MACROPHAGES (FORMATION OF PORES IS ACCELERATED BY DISEASE INVOLVING PARYNCHYMA AND THE NUMBER AND SIZE OF PORES INCREASE PROGRESSIVELY WITH AGE)  ALVEOLAR MACROPHAGES AKA TYPE III ALVEOLAR CELLS MAJOR ROLE IN REMOVAL OF BACTERIA AND FOREIGN PARTICLES BELIEVED TO ORIGINATE FROM STEM CELLS PRECURSORS IN BONE MARROW AND PRESUMABLY MIGRATE THROUGH BLOOD STREAM TO LUNGS AND ARE EMBEDDED IN EXTRACELLULAR LINING OF ALVEOLAR SURFACE ALVEOLAR MACROPHAGES REPRODUCE WITHIN THE LUNGS  ALVEOLAR INTERSTITIUM ALVEOLAR CAPILLARY CLUSTERS SURROUNDED , SUPPORTED AND SHAPED BY THE INTERSTITIUM GEL LIKE SUBSTANCE COMPOSED OF HYALURONIC ACID MOLECULES HELD TOGETHER BY A WEBLIKE NETWORK OF COLLAGEN FIBERS INTERSTITIUM HAS 2 MAJOR COMPARTMENTS TIGHT SPACE AREA BETWEEN THE ALVEOLAR EPITHELIUM AND THE ENDOTHELIUM OF PULMONARY CAPILLARIES THE AREA WHERE MOST GAS EXCHANGE OCCURS LOOSE SPACE AREA THAT SURROUNDS THE BRONCHIOLES, RESPIRATORY BRONCHIOLES, ALVEOLAR DUCTS, AND ALVEOLAR SACS LYMPHATIC AND NEURAL FIBERS FOUND IN LOOSE SPACE WATER CONTENT CAN INCREASE IN LOOSE SPACE COLLAGEN IN INTERSTITIUM BELIEVED TO LIMIT ALVEOLAR DISTENSIBILITY EXPANSION OF A LUNG BEYOND THE LIMITS OF THE INTERSTITIAL COLLAGEN CAN OCC;LUDE PULMONARY CAPILLARIES DAMAGE STRUCTURAL FRAMEWORK OF THE COLLAGEN FIBERS AND THE WALL OF THE ALVEOLI INTERSTITIUM  PULMONARY CIRCULATION LUNGS SUPPLIED BY 2 CIRCULATIONS BRONCHIAL CIRCULATION PULMONARY CIRCULATION  BRONCHIAL CIRCULATION ARISES FROM LEFT HEART PULMONARY VEIN SUPPLIES OXYGENATED BLOOD TO TRACHEOBRONCHIAL TREE DOWN TO THE LEVEL OF TERMINAL BRONCHIOLES BELOW LEVEL OF TERMINAL BRONCHIOLES  LUNG TISSUE IS SUPPORTED BY A COMBINATION OF ALVEOLAR GAS AND THE PULMONARY CIRCULATION 2-3% OF OUTPUT OF LEFT VENTRICLE  BRONCHIAL CIRCULATION PA – pulmonary artery BT – terminal bronchiole PV – pulmonary vein  PULMONARY ARTERIES PV supply to level of terminal bronchiole  PULMONARY CIRCULATION RECEIVES TOTAL OUTPUT FROM THE RIGHT HEART VIA THE PULMONARY ARTERY PULMONARY ARTERY DIVIDES INTO RIGHT AND LEFT PULMONARY ARTERY TO SUPPLY EACH LUNG DEOXYGENATED BLOOD PASSES THROUGH THE PULMONARY CAPILLARIES WHERE CO2 IS ELIMINATED AND O2 IS TAKEN UP. OXYGENATED BLOOD RETURNED TO LEFT HEART (LEFT ATRIUM) VIA 4 PULMONARY VEINS. PULMONARY CIRCULATION  2 PULMONARY VEINS SUPPLY OXYGENATED BLOOD BACK TO LEFT ATRIUM PULMONARY VASCULAR SYSTEM INDEPENDENT NETWORK PURPOSE  DELIVERING BLOOD TO AND FROM LUNGS FOR PURPOSE OF GAS EXCHANGE PROVIDES NUTRITIONAL SUBSTANCES TO STRUCTURES DISTAL TO TERMINAL BRONCHIOLES COMPOSED OF ARTERIES ARTERIOLES CAPILLARIES (PULM/CAPILLARY BED DENSEST OF CAPILLARY NETWORKS) VENULES VEINS  ARTERIES RIGHT VENTRICLE PUMPS BLOOD TO PULMONARY ARTERY CARRIES DEOXYGENATED BLOOD TO LUNGS PULMONARY ARTERY DIVIDES INTO RIGHT AND LEFT BRANCHES PULMONARY ARTERIES ENTER LUNGS THROUGH THE HILUM BRONCHI, VESSELS AND NERVES ENTER THROUGH THE HILUM PULMONARY ARTERY FOLLOWS THE TRACHEOBRONCHIAL TREE IN A POSTERIOR LATERAL FASHION DIVIDING AS THE TRACHEOBROCHIAL TREE DOES  PULMONARY ARTERY 3 LAYERS OF TISSUE TUNICA INTIMA ENDOTHELIUM THIN LAYER OF CONNECTIVE TISSUE TUNICA MEDIA THICKEST LAYER ELASTIC CONNECTIVE TISSUE (LARGER ARTERIES) SMOOTH MUSCLE (MEDIUM TO SMALLER ARTERIES) TUNICA ADVENTITIA OUTERMOST LAYER CONNECTIVE TISSUE CONTAINS SMALL VESSELS THAT NOURISH ALL THREE LAYERS  ARTERIOLES SUPPLY NUTRIENTS TO RESPIRATORY BRONCHIOLES ALVEOLAR DUCTS ALVEOLI ELASTIC AND SMOOTH MUSCLE FIBERS GRADUALLY DISAPPEAR BEFORE ENTERING ALVEOLAR/CAPILLARY SYSTEM DISTRIBUTION AND REGULATION OF BLOOD CALLED RESISTANCE VESSELS  CAPILLARIES PULMONARY CAPILLARIES SURROUND ALVEOLI COMPOSED OF SINGLE ENDOTHELIAL (SINGLE LAYER OF SQUAMOUS EPITHELIAL CELLS) 0.1 Μ THICK AND EXTERNAL DIAMETER IS 10Μ MAJOR SITE OF GAS EXCHANGE SELECTIVE PERMEABILITY TO WATER ELECTROLYTES SUGARS  CAPILLARIES MAJOR BIOCHEMICAL ROLE IN PRODUCTION AND DESTRUCTION OF A BROAD RANGE OF BIOLOGICALLY ACTIVE SUBSTANCES SEROTONIN NOREPINEPHERINE Destroyed by pulmonary capillaries PROSTAGLANDINS SOME PROSTAGLANDINS ARE PRODUCED AND SYNTHESIZED BY PULMONARY CAPILLARIES SOME CIRCULATING INACTIVE PEPTIDES ARE CONVERTED TO ACTIVE FORM (ANGIOTENSIN I IS CONVERTED TO ANGIOTENSIN II)  VENULES AND VEINS BLOOD MOVES PULMONARY CAPILLARIES  PULMONARY VENULES (TINY VEINS CONTINUOUS WITH CAPILLARIES) CAPITANCE VESSELS  PULMONARY LYMPHATIC SYSTEM LYMPHATIC VESSELS ARE FOUND SUPERFICIALLY AROUND THE LUNGS BENEATH THE VISCERAL PLEURA IN THE DENSE CONNECTIVE TISSUE WRAPPING THE BRONCHIOLES, BRONCHI, PULMONARY ARTERY, PULMONARY VEINS PRIMARY FUNCTION REMOVE EXCESS FLUID AND PROTEIN MOLECULES THAT LEAK OUT OF PULMONARY CAPILLARIES DEEP IN LUNGS, LYMPHATIC VESSELS ARISE FROM LOOSE SPACE OF INTERSTITIUM.  LYMPHATIC SYSTEM HAVE SINGLE LEAF FUNNEL SHAPED VALVES DIRECT LYMPHATIC FLOW TOWARD THE HILUM LARGER LYMPHATIC CHANNELS SURROUNDED BY SMOOTH MUSCLE BANDS  PERISTALIC MOVEMENT OF FLUID REGULATED BY ANS t al To ph m Ly ow u fl /ho l m M 20 M& r  LYMPH NODES ORGANIZED COLLECTIONS OF LYMPHATIC TISSUE PRODUCE LYMPHOCYTES AND MONOCYTES ACT AS FILTERS  KEEPING PARTICULATE MATTER AND BACTERIA FROM ENTERING BLOOD STREAM THERE ARE NO LYMPHATIC VESSELS IN THE WALLS OF THE ALVEOLI SOME ALVEOLI ARE LOCATED IMMEDIATELY ADJACENT TO PERIBRONCHOVASCULAR LYMPHATIC VESSELS (JUXTA- ALVEOLAR LYMPHATICS) THOUGHT TO ASSIST IN REMOVAL OF EXCESS FLUID AND FOREIGN MATERIAL THAT ENTER INTERSTITIAL SPACE. LYMPH NODES NERVOUS INNERVATION  INNERVATION DIAPHRAGM INNERVATED BY PHRENIC NERVES ARISE FROM C3-C5 NERVE ROOTS INTERCOSTALS INNERVATED BY RESPECTIVE THORACIC NERVE ROOT SYMPATHETIC AND PARASYMPATHETIC INNERVATION OF BRONCHIAL SMOOTH MUSCLE AND SECRETORY GLANDS IS PRESENT  Innervation Vagus nerve  sensory innervation VAGUS MEDIATION OF SYMPATHETIC PARASYMPATHETIC T1-T4 T1-T4 B2 BRONCHODILATION AND BRONCHOCONSTRICTION DECREASE SECRETIONS INCREASED SECRETIONS MUSCARINIC RECEPTORS Α2 ADRENERGIC RECEPTOR STIMULATION MAY  BRONCHOCONSTRICTION AND DECREASE SECRETIONS ADRENERGIC RECEPTORS THE LUNGS APEX (TOP) POINTED BASE BROAD AND CONCAVE (TO ACCOMMODATE CONCAVE DIAPHRAM) APICES RISE TO LEVEL OF FIRST RIB BASES EXTEND ANTERIORLY TO LEVEL OF 6TH RIB (XIPHOID PROCESS) POSTERIORLY TO 11TH RIB MEDIASTINAL BOARDERS ARE CONCAVE TO FIT MEDIASTINAL STRUCTURES. CENTER OF THE MEDIASTINAL BOARDER IS THE HILUM ANATOMIC RELATIONSHIP OF LUNG AND THORAX HILUM 1. HILUM 2. OBLIQUE FISSURE 3. LEFT PULMONARY ARTERY 4. LEFT MAIN BRONCHUS 5. PULMONARY LIGAMENT 6. APEX 7. RIGHT PULMONARY VEIN 8. BRONCHOPULMONARY (HILAR)LYMPH NODES 9. RIGHT SUPERIOR LOBAR BRONCHUS  RIGHT AND LEFT LUNGS RIGHT LUNG LEFT LUNG LARGER AND HEAVIER 2 LOBES 3 LOBES UPPER UPPER LOWER MIDDLE SEPARATED BY LOWER OBLIQUE FISSURE LOBES SEPARATED BY OBLIQUE FISSURE CARDIAC NOTCH HORIZONTAL FISSURE 8 10 BRONCHOPULMONARY BRONCHOPULMONARY SEGMENTS SEGMENTS  Bronchopulmonary segments RIGHT LUNG (10) LEFT LUNG(8) RIGHT UPPER LOBE LEFT UPPER LUNG APICAL APICAL POSTERIOR ANTERIOR POSTERIOR ANTERIOR RIGHT MIDDLE LOBE SUPERIOR LINGUAL MEDIAL INFERIOR LINGAL LATERAL LEFT LOWER LOBE RIGHT LOWER LOBE SUPERIOR SUPERIOR ANTERIOR BASAL ANTEROMEDIAL BASAL POSTERIOR BASAL POSTERIOR BASAL LATERAL BASAL LATERAL BASAL MEDIAL BASAL  MEDIASTINUM CAVITY CONTAINS ORGANS AND TISSUES IN THE THORACIC CAGE BETWEEN RIGHT AND LEFT LUNG BORDERED BY STERNUM THORACIC VERTABRAE CONTAINS HEART TRACHEA MAJOR BLOOD VESSELS (GREAT VESSELS) NERVES PORTIONS OF ESOPHAGUS THYMUS GLAND LYMPH NODES  STRUCTURES SURROUNDING THE LUNGS PLEURA DOUBLE-WALLED SEROUS MEMBRANE COVERING THE LUNGS 2 LAYERS VISCERAL PLEURA TIGHTLY ADHERENT TO LUNG SURFACE PARIETAL PLEURA LINES INTERIOR OF CHEST WALL AND DIAPHRAGM TWO LAYERS MEET AT THE HILUM PLEURAL SPACE/ PLEURAL CAVITY POTENTIAL SPACE BETWEEN VISCERAL PLEURA AND PARIETAL PLEURA STRUCTURES SURROUNDING THE LUNGS  Conditions Affect Pleural Space MATERIAL IN PLEURAL SPACE MEDICAL NAME AIR PNEUMOTHORAX AIR UNDER PRESSURE TENSION PNEUMOTHORAX BLOOD HEMOTHORAX SEROUS FLUID PLEURAL EFFUSION LYMPH EMYEMA OR PYOTHORAX ORGANIZED BLOOD CLOT FIBROTHORAX  THE DIAPHRAGM MAJOR MUSCLE OF VENTILATION DOME SHAPED MUSCULOFIBROUS PARTITION BETWEEN THROACIC AND ABDOMINAL CAVITY Fast twitch fibers  COMPOSED OF 2 SEPARATE MUSCLES strength (greater O2 RIGHT HEMI-DIAPHRAGM demand) LEFT HEMI-DIAPHRAGM Slow tiwtch fibers  resist fatigue EACH HEMIDIAPHRAGM ARISE FROM endurance LUMBAR VERTEBRAE …Barash COSTAL MARGIN XIPHOID PROCESS 2 MUSCLES MERGE AT MIDLINE INTO A BROAD SHEET CALLED “CENTRAL TENDON” PIERCED BY ESOPHAGUS AORTA NERVES  DIAPHRAGM INNERVATION PHRENIC NERVE WHICH ARISE FROM C3-C5 NERVE ROOT UNILATERAL PHRENIC NERVE BLOCK ↓ 25% BILATERAL PHRENIC NERVE PALSIES  SEVERE IMPAIRMENT INTERCOSTAL MUSCLES ARE INNERVATED BY THEIR RESPECTIVE THORACIC NERVE ROOTS CERVICAL CORD INJURIES ABOVE C5 ARE INCOMPATIBLE WITH SPONTANEOUS VENTILATION BECAUSE BOTH PHRENIC AND INTERCOSTALS ARE AFFECTED PARALYZED DIAPHRAGM CANNOT CONTRACT AND WILL (RELAX) MOVE UPWARD THE DIAPHRAGM  RIB CAGE EACH RIB EXCEPT LAST 2 ARTICULATE ANTERIORLY WITH THE STERNUM AND POSTERIORLY WITH THE VERTEBRAE TO HELP WIT UPWARD OUTWARD EXPANSION OF THE RIBCAGE – ALLOWS FOR CHEST EXPANSION  INSPIRATION DURING NORMAL VENTILATION (HEALTHY PERSON), DIAPHRAGM ALONE CAN MANAGE TASK OF MOVING GAS IN AND OUT OF LUNGS WHEN STIMULATED TO CONTRACT DIAPHRAGM MOVES DOWNWARD 1-2 CM EUPNEIC BREATHING 10CM DURNG FORCEFUL BREATHING LOWER RIBS MOVE UPWARD AND OUTWARD ↑ VOLUME OF THORACIC CAVITY ↓ INTRATHORACIC PRESSURE ↓ INTRAPLEURAL PRESSURE ↓ INTRA-ALVEOLAR PRESSRUE (BECOMES NEGATIVE) AS A RESULT GAS FLOWS FROM ATMOSPHERE INTO LUNGS  INSPIRATION DURING NORMAL VENTILATION (HEALTHY PERSON), DIAPHRAGM ALONE CAN MANAGE TASK OF MOVING GAS IN AND OUT OF LUNGS WHEN STIMULATED TO CONTRACT DIAPHRAGM MOVES DOWNWARD 1-2 CM EUPNEIC BREATHING Di a 10CM DURNG FORCEFUL BREATHING for phrag che 75% m acc st v of c o LOWER RIBS MOVE UPWARD AND OUTWARD olu han unts me g !! e in ↑ VOLUME OF THORACIC CAVITY ↓ INTRATHORACIC PRESSURE ↓ INTRAPLEURAL PRESSURE ↓ INTRA-ALVEOLAR PRESSRUE (BECOMES NEGATIVE) AS A RESULT GAS FLOWS FROM ATMOSPHERE INTO LUNGS In order for airflow to enter lungs alveolar pressure must be less than atmospheric pressure Can be achieved by Positive pressure ventilation Spontaneous ventilation (negative pressure breathing)  EXPIRATION NORMAL EUPNEIC EXPIRATION  FROM PASSIVE RECOIL OF CHEST WALL AND DOES NOT REQUIRE MUSCLE CONTRACTION DIAPHRAGM RELAXES AND MOVES UPWARD INTO THORACIC CAVITY INCREASE ALVEOLAR PRESSURE INCREASE INTRAPLEURAL PRESSURE CAUSING GAS TO FLOW OUT OF LUNGS ACCESSORY MUSCLES OF RESPIRATION INSPIRATION UTILIZED DURING VIGOROUS EXERCISE ADVANCED COPD DISTRESS ACESSORY MUSCLES ASSIST DIAPHRAGM IN CREATING SUBATMOSPHERIC PRESSURE IN LUNGS TO ENABLE ADEQUATE INSPIRATION ACCESSORY MUSCLES OF INSPIRATION ARE SCALENE MUSCLES Barash: STERNOCLEIDOMASTOID MUSCLES Sternocleidomastoid PECTORALIS MAJOR MUSCLES Back muscles: TRAPEZIUS MUSCLES Pectoralis major and minor Latissimus dorsi EXTERNAL INTERCOSTAL MUSCLES Serratus anterior  CERVICAL STRAP MUSCLES DEEP CERVICAL STRAP MUSCLES MOST IMPORTANT INSPIRATORY ACCESSORY MUSCLES IMPORTANCE IS MAGNIFIED WHEN DIAPHRAGMATIC FUNCTION IS IMPAIRED AS SEEN WITH CERVICAL SPINAL CORD TRANSSECTION LOSS OF DIAPHRAGM FUNCTION LOSS OF INTERCOSTAL FUNCTION Cervical strap muscles are most important inspriatory accessory muscle… Barash  SCALENE MUSCLES 3 SEPARATE MUSCLES FUNCTION AS A UNIT ANTERIOR MEDIAL POSTERIOR ORIGINATE ON TRANSVERSE PROCESS C6 INSERT INT 1ST AND 2ND RIB PRIMARY FUNCTION FLEX THE NECK ELEVATE FIRST AND SECOND RIB DURING INSPIRATION DECREASING INTRAPLEUAL PRESSURE  STERNOCLEIDOMASTOID MUSCLES LOCATED EACH SIDE OF THE NECK ORIGINATE FROM STERNUM AND CLAVICLE INSERT INTO MASTOID PROCESS AND OCCIPITAL BONE NORMALLY THEY PULL FROM STERNOCLAVICULAR ORIGIN AND ROTATE THE HEAD OPPOSITE TURN AS ACCESSORY RESPIRATORY MUSCLE IT PULLS FROM INSERTION ON SKULL AND ELEVATES THE STERNUM INCREASES AP DIAMETER OF CHEST  PECTORALIS MAJOR MUSCLES POWERFUL FAN SHAPED EACH SIDE OF UPPER CHEST ORIGINATE FROM CLAVICLE AND STERNUM INSERT INTO UPPER PART OF HUMERUS WHEN USED AS ACCESSORY MUSCLE PULL FROM HUMERAL INSERTION AND ELEVATE CHEST INCREASE AP DIAMETER OF CHEST MUSCLE USED IN COPD  TRAPEZIUS MUSCLES LARGE, FLAT SITUATED ON UPPER BACK AND NECK ORIGINATE  OCCIPITAL BONE, LIGAMENTUM NUCHAE, AND SPINOUS PROCESS OF C7 AND ALL THORACIC VERTABRAE INSERT INTO SPINE OF SCAPULA, ACROMION PROCESS AND LATERAL THIRD CLAVICLE NORMALLY THEY ROTATE THE SCAPULA, RAISE THE SHOULDERS AND ABDUCT AND FLEX ARMS AS RESP. ACCESSORY MUSCLE HELP TO ELEVATE THE THORACIC CAGE EXTERNAL INTERCOSTAL MUSCLES ARISE FROM LOWER BOARDER OF EACH RIB INSERT INTO UPPER BOARDER OF RIB BELOW ANTERIORLY FIBERS RUN DOWN AND MEDIAL POSTERIORLY FIBERS RUN DOWN AND LATERAL CONTRACT DURING INSPIRATION AND PULL RIBS UPWARD AND OUTWARD INCREASING LATERAL DIAMETER AND AP DIAMETER OF THORAX INCREASES LUNG VOLUME PREVENTS RETRACTION OF INTERCOSTAL SPACE DURING AND EXCESSIVE FORCEFUL INSPIRATION  ACCESSORY MUSCLES OF EXPIRATION ASSIST IN EXHALATION WHEN AIRWAY RESISTANCE BECOMES SIGNIFICANTLY ELEVATED INCREASE INTRAPLEURAL PRESSURE AND OFFSET INCREASED INCREASED AIRWAY RESISTANCE MAJOR MUSCLES OF EXHALATION ARE: RECTUS ABDOMINIS MUSCLES EXTERNAL ABDOMINIS OBLIQUE MUSCLES INTERNAL ABDOMINIS OBLIQUE MUSCLES TRANSVERSE ABDOMINIS MUSCLES INTERNAL INTERCOSTAL MUSCLES ABDOMINAL MUSCLES OF EXHALATION  RECTUS ABDOMINIS MUSCLES PAIRED OF MUSCLES EXTEND ENTIRE LENGTH OF ABDOMEN SEPARATED BY LINEA ALBA ARISE FROM ILIAC CREST AND PUBIC SYMPHYSIS INSERT INTO XIPHIOD PROCESS AND 5,6,7TH RIBS WHEN CONTRACTED:  EXTERNAL ABDOMINIS OBLIQUE BROAD, THIN LOCATED ON ANTEROLATERAL SIDES OF ABDOMEN LONGEST AND MOST SUPERFICIAL OF ALL ANTERLATERAL ABDOMINAL MUSCLES ARISE BY 8 DIGITATIONS FROM THE LOWER 8 RIBS AND INSERT INTO THE ILIAC CREST AND LINEA ALBA WHEN CONTRACTED THEY ASSIST IN COMPRESSING THE ABDOMINAL CONTENTS WHICH PUSH DIAPHRAGM INTO THE THORACIC CAGE ASSISTING EXHALATION  INTERNAL ABDOMINIS OBLIQUE SMALLER AND THINNER THAN EXTERNAL OBLIQUE LOCATED IN LATERAL AND VENTRAL PARTS OF ABDOMINAL WALL UNDER THE EXTERNAL OBLIQUES ARISE FROM INGUINAL LIGAMENT, ILIAC CREST AND LOWER PORTION OF LUMBAR APONEUROSIS ASSIST IN EXHALATION BY COMPRESSING THE DIAPHRAGM INTO THORACIC CAGE.  TRANSVERSE ABDOMINIS MUSCLES FOUND IMMEDIATELY UNDER THE INTERNAL ABDOMINIS MUSCLES ARISE FROM INGUINAL LIGAMENT AND ILIAC CREST, THE THORACOLUMBAR FASCIA AND LOWER 6TH RIBS AND INSERT INTO THE LINEA ALBA. WHEN CONTRACTED  THEY HELP TO CONSTRICT ABDOMINAL CONTENTS ACCESSORY MUSCLES OF EXHALATION WHEN ALL 4 PAIRS OF ACCESSORY MUSCLE OF EXHALATION CONTRACT THEY DRIVE THE DIAPHRAGM INTO THE THORACIC CAGE. INTRAPLEURAL PRESSURE INCREASES ENHANCING AMOUNT OF GAS FLOW EXHALED  INTERNAL INTERCOSTAL MUSCLES RUN BETWEEN RIBS DIRECTLY BENEATH EXTERNAL INTERCOSTALS ARISE FROM INFERIOR BOARDER OF EACH RIB INSERT INTO SUPERIOR BOARDER OF RIB BELOW ANTERIORLY FIBERS RUN IN DOWNWARD AND LATERAL DIRECTION POSTERIORLY FIBERS RUN DOWNWARD AND IN A MEDIAL DIRECTION CONTRACT DURING EXPIRATION AND PULL RIBS DOWNWARD AND INWARD DECREASING BOTH LATERAL AND AP DIAMETER OF THE THORAX (ANTAGONISTIC ACTION OF EXTERNAL INTERCOSTALS DURING ISNPIRATION) RESULT  DECREASED LUNG VOLUME AND OFFSETS INTERCOSTAL BULDGING DURING EXCESSIVE EXPIRATION MUSCLES OF RESPIRATION 1. STERNOCLEIDOMASTOID 2. SCALENES (ANTERIOR, MIDDLE, POSTERIOR) 3. EXTERNAL INTERCOSTALS 4. INTERCHONDRAL PART OF INTERCOSTALS 5. DIAPHRAGM 6. INTERNAL INTERCOSTALS 7. ABDOMINALS (RECTUS, EXTERNAL OBLIQUE, INTERNAL OBLIQUE, TRANSVERSUS)  FOR YOUR CONVENIENCE MUSCLES OF MUSCLES OF INSPIRATION EXPIRATION SCALENE MUSCLES RECTUS ABDOMINIS STERNOCLEIDOMAS MUSCLES TOISD MUSCLES EXTERNAL PECTORALIS MAJOR ABDOMINIS MUSCLES OBLIQUE MUSCLES TRAPEZIUS INTERNAL MUSCLES ABDOMINIS EXTERNAL OBLIQUE MUSCLES INTERCOSTAL TRANSVERSE QUESTIONS AND DISCUSSION