Impuesto sobre el Alcohol y Bebidas Derivadas

Elevates ribs 

External intercostals □

Pulls dome downwards to increase the superior-inferior dimensions of the lungs (increases lung volume) 

Diaphragm □

Quiet Breathing 

Further elevate the most superior portion of the thoracic cage so work with the external intercostal muscles 

Need accessory muscles to help … i.e. SCM + scalenes □

Forceful inspiration 

Relies on the elastic recoil properties of the lung … like letting a balloon to deflate □

Quiet breathing (expiration) 

Depress ribs 

Internal intercostals □

Internal/External oblique + transverse/rectus abdominus 

Help compress the andomino-pelvic cavity which pushes the viscera up to the diaphragm, helping move it in a superior direction  Abdominal muscles □ Active breathing  ○ Muscles of Breathing • From in to out … ○

Single layer of epithelial cells that secrete serous fluid which helps lubricate the pleural cavity 

Parietal pleura ○

Internal intercostals ○

In the inferior aspect of the rib □

The nerve is the thoracic spinal nerve 

For each intercostal space, its a separate thoracic level of a spinal nerve … its segmental innervation 

In the groove is the VAN □ Costal groove  Ribs ○ External intercostals ○

If you want to pull excess fluid off the heart (tamponade) or pneumothorax, want to get a needle in there to remove the excess fluid or air … the safest way is the aim for the superior aspect of a rib … avoid the intercostal VAN …

 Importance ○ Intercostal VAN • Anastomoses … ○

There is anastomoses for both the arterial and venous blood circuits □

General 

L/R thoracic arteries supply it … branch off the subclavian (also known as the mammary artery and is good for CABG) 

Anterior intercostal artery □

Descending aorta supplies is 

Posterior intercostal artery □

Arteries 

Anterior intercostal vein □

Posterior intercostal vein □

Vein 

Internal thoracic vein eventually dumps into the subclavian vein 

Front: □

Hemiazygous V ◊

Hemi cause its half the size as the vein on the right (azygous) ◊

Will drain into azygous (cross from left to right) which dumps into SVC ◊ Left side:  Azygous vein ◊ Right side:  Back: □ Venous drainage  ○

Thoracic Cage - Blood Supply •

Contains a central tendon 

Central tendon ○

Diaphragmatic Origin Schematic •

Contains a central tendon 

Aponeurosis 

Anterior: Attach to the inferior margin of the ribcage out front 

Crosses T12 and goes to the other side □

Posterior: Runs along the inferior margin of the 12th thoracic rib 

Skeletal muscles ○

Pulls central tendon downwards □

Diaphragm moves inferiorly … helps bring air into lungs 

Both active and passive 

Inspiration ○

Travels through the fibrous pericardium to enter the diaphragm 

Supplied by the phrenic nerve (C3,4,5) ○

Aorta 

Esophagus 

Inf. Vena Cava 

Pass through the openings in the diaphgragm 

Many structures pass through the diaphragm… ○

This is where the diaphragm is said to have two legs through which the aorta comes □

Thoracic duct comes through

□

Aortic hiatus (hole in the muscle) 

Vagus nerve follows esophagus

□

Esophageal hiatus 

Doesn’t go through muscle □

Tendon is dense connective tissue … helps maintain patency of IVC that passes through it □

Caval opening 

Openings ○

Air enters through external nares (openings for your nasal cavity) □

Nose 

Surround the superior, middle and inferior nasal meatuses (openings) 

Warms the air 

Humidifies the air (mucous has water component which evaporates into the air) 

Lined by mucous membrane to trap particulate matter □

Bony protrusions 

Stets up turbulent air flow, forcing air to the sides of the nasal cavity, forcing it on the mucous 

Nasal Chonche □

Cause it's hard to tell whether there are 1-2 layers … cells constantly dividing ◊

Psuedostratified 

Have cilia to move mucous to the back of the mouth … then you can swallow or spit the mucous ◊

Ciliated 

Find pseudostratified, ciliated columnar □

Nasal cavity 

Sinuses 

Upper most region 

Associated with the nasal cavity 

Nasopharynx □

Behind the oral cavity … represents a structure that is a conduit of both air and food 

Oropharynx □

A structure that is a conduit of air and food 

Found in the region of the larynx 

Laryngopharynx □

Pharynx 

Has to crisscross over the airways … the epiglottis is there to prevent that □

Note: Food 

Trapped between the trachea and the vertebral column at the back □

When you swallow food, the esophagus will protrude into the trachea, which has smooth muscle at the back leaving it soft so food can push past □

Esophagus 

Pseudostratified, ciliated columnar in the nasal cavity □

Rest of the places 

So you can stop the abrasive forces  Stratified squamous □ Cells  Upper Airways: ○

Upper Respiratory System •

Larynx extends from C4-C6. ○

Glottis = is an inward folding of the edges of the larynx … also known as the false vocal cord



Air leaves the pharynx and enters the larynx via the glottis. ○

Protects the lower airways from food entering □

Epiglottis 

Sits above the thyroid gland so doesn’t protect the thyroid gland □

Represents the fusion of two cartilages … makes the Adam's apple due to the 900_{angle … in females the angle is larger so don’t have an Adam's}

apple □ Thyroid 

Defines the inferior border of the larynx □

Cricoid 

Three main cartilages form larynx (other smaller ones for a total of 9). ○

Connective tissue from cartilage to cartilage 

Vibrate to make sound 

This represents the division of the upper airways from the lower airways 

Everything above the vocal cords is not sterile and below is clean 

Ligaments (including vocal ligaments) found in this area ○

Epiglottis serves to protect lower airways during deglutition (swallowing) Larynx

Food stuff passing from the oral cavity at the front have to get behind into the esophagus … 

Closure is aided by the fact that the larynx during swallowing moves superiorly to help the epiglottis seal off the opening for the trachea □

Epigottis has to close down to prevent food from getting in there 

Epiglottis serves to protect lower airways during deglutition (swallowing) ○

Functions 

During swallowing, vomiting 

Close off trachea ○

During these maneouvers you generate a lot of pressure in the thoracic cavity and lungs … the only way to do that is to close the glottis and then contract the muscles of expiration to generate the pressure in the lungs … you then open the glottis to release the pressure



Send the air out through the lungs in high velocity usually through the oral cavity □

Have irritant receptors in the lower airways, in the primary bronchi to generate this □

Cough 

Trying to get rid of irritants that have stimulated irritant receptors in the upper airways (nasal cavity) … so you direct your air through the nasal cavity □ Sneeze  Generate Cough/sneeze ○

Have to close the epiglottis so the thorax and diaphragm cant move up as your contracting the abdominal muscle □

Pressure goes onto the large colon □

Valsalva maneuver (defecation)  Peeing  Childbirth  Expulsive maneuvers ○

If your trying to lift something 

Structural support ○

Epiglottis •

Warming it 

Making it moist 

Removing as much particulate matter as possible 

Responsible for helping to condition the incoming air ○

Still filtering air 

Air doesn’t exert as much pressure on the walls of vessels like blood does, so unless you close your glottis to make pressure, you need something to keep the airways open

□

Provides structural support to maintain patency of airways to let the air get in 

Lower airways also does many of the same thing ○

Upper airways •

Right below larrynx ○

~12cm long by ~2.5cm in diameter

○

This provides structural support 

Tracheal smooth muscle (trachealis muscles) (under autonomic control) finishes the circle 

Contains 16-20 C-shaped cartilage structures ○

Direct air into left or right lung 

At this bifurcation, there is the carina 

Rigid structure divides into primary bronchi ○

Help generate the mucociliary apparatus … so mucous that traps stuff will be moved up the larynx … can spit the stuff out then or digest it

□

Pseudostratified, ciliated columnar epithelium 

Lining of epithelium provides same protection as nasal cavity and larynx ○

Trachea •

Trachea ○

Internal ridge at bronchial junction (assoc. cough reflex) □

Epithelial tissue has irritant receptors … so particulates will generate a cough reflex □

Carina  Bifurcation ○

Divide into right and left lung? Or divide at the right and left lung … 

From slide: Primary bronchi enter each lung at the hilus then divide into secondary bronchi 

Divide into right and left lung at the hilus (special names cause other cool stuff enters and exits the lungs at this point) □

Primary bronchi 

Shorter, more vertical □

Therefore food will prob go this side more than the left side 

Right bronchus almost goes straight down □

Right primary 

Longer, more angled □

This is because we have the heart sitting there □

Left primary 

Primary bronchi ○

Secondary (lobar) bronchi for each lobe (3 in Right, 2 in Left) 

Direct air into the separate lobes of the lung  Secondary bronchi ○ Successive Structure • Superior  Middle  Inferior  Lobes □

Grooves that run into the lung tissue) ◊

Between superior and middle ◊

Horizontal fissure 

Between middle and inferior ◊ Oblique fissure  Fissures □ Right 

Is its own bronchopulmonary segment ◊

Lingula - end of the superior lobe ◊

Superior □

Inferior □

(have heart occupying the space) □ Lobes □ Oblique fissure □ Fissures □ Left 

Lobes and Fissures ○ Lungs • iClicker - Trachea (?) •

Lower Airawys

Tuesday, February 5, 2013 2:02 PM

Is involved in conditioning incoming air ○

Is not an upper airway structure ○

Not supported by plates of cartilage (its rings) ○

Its not posterior to the esophagus and is not supported by the pulmonary circuit ○

iClicker - Trachea (?) •

Secondary bronchi continue dividing to create tertiary (segmental) bronchi ○

10 right lung, 8* in left lung ○

Area supplied by tertiary bronchi 

Functionally and anatomically independant □

Subsections of each lobe of the lung 

10 on right side and 8 on the left 

If you have cancer, you can remove one segment of the lung and the others will be just fine 

Bronchopulmonary segment. ○

From the trachea, they gradually disappear and are replaced by cartilage plates. 

The plates are shields without the hole at the back 

Cartilage rings ○

Divide into bronchioles … ○

Tertiary bronchi •

Eventually cartilage is replaced by smooth muscle only. ○

Spiral smooth muscle bands regulated by the ANS. ○

This provides that elastic recoil property of the lung which aids in you doing passive expiration □

At the terminal bronchiole, all you have is elastic fibers (no cartilage) □

Important for asthma cause its not the trachea or primary bronchi … it’s the airways at the level of the terminal bronchioles that get affected

□

As you go down further, the cartilage disappears and gets replaced with elastic tissue … also see smooth muscle 

This is the smaller bronchioles all the way up to the terminal bronchioles that are affected □

Smooth muscle component of the airways becomes a bigger factor in the distal airways … parasymp innervation causes contractio n = increases resistance in the airways



Bronchioles branch up to 14X to make terminal bronchioles. ○

Bronchioles •

This represents the division between the conducting zone of the lungs (bringing air in, filtering and humidifying it) … and t hen respiratory region where there is gas exchange



Each terminal bronchiole forms a lobule ○

Terminal bronchiole 

Apart of the pulmonary circuit … comes off of RV and going back to LA respectively □

Arteriole + Venule 

Lymphatic vessels 

Gives that recoil property □

All wrapped in elastic tissue 

Each lobule is composed of a: ○

So thin that there can be gas exchange between blood and air 

Terminal bronchioles divide into respiratory bronchioles ○

Alv ducts conduct air to individual alveoli 

Respiratory bronchioles connected to alveolar sacs by alveolar ducts ○

Lobule (acinis) •

Walls of the airways are so thick so just gas exchange will not work for those walls … need a circuit that gives oxygenated b lood 

This is the bronchiole circuit 

Bronchial arteries service the conducting regions. 

Coming off the LV of the heart (descending aorta) 

Have to follow all the structures down (like trachea down … to the terminal bronchiole) 

Trachea → Terminal bronchioles ○

Starts at the acinis 

At and after the lobules, no it’s the pulmonary circuit that is playing a role 

These come off the RV of the heart 

Goes to a capillary bed that surrounds each alveolus, participated in gas exchange and then the blood will go back to the LA 

Pulmonary arteries service the gas exchange regions. ○

Circulations in the lung •

Each division represents a division ○

At each level the division is mostly dichotomous (two by two by two) ○

Trachea is generation 0 ○

Primary bronchii are generation 1 ○

Gen 15-23 

Begins with respiratory bronchiole … all the way to gen 23 = alveoli 

Gas exchange ○

Generations •

Warming, humidifying and filtering 

Air has traveled through the external nares, nasal cavity, is funneled into the pharynx, through the glottis to the larynx (start of lower airways approx) and into the trachea

○

The trachea splits into the primary bronchi which divide into the secondary bronchi. These further subdivide into tertiary bronchi ○

Tertiary bronchi eventually split into terminal bronchioles which form lobules (acini). ○

Terminal bronchioles split into respiratory bronchioles which end in clusters of alveoli called alveolar sacs. ○

Conducting Summary so far •

 Conducting ○



Now the airways are microscopic cause you need a microscope to see them 

Respiratory ○

Surface area in the other parts is not as much to make it that significant □

This is at the acinis of the lung … mostly at the the alveoli part of it 

Interface of the capillaries of the pulmonary circuit and the alveoli 

Gas exchange occurs at alveolar-capillary membrane. ○

300 million alveoli with surface area totaling 750 sq ft (~70 m2) ○

Gas Exchange Membrane •

Air cell □

Squamous in nature -- provide greatest SA and therefore is primary site of gas exchange. □

Continuous lining of alveolar wall. □

Type I alveolar cells (pneumocyte) 

Secrete a liquid called surfactant. □

See the mucous has water and water likes to attract each other (cohesion) (as well as adhesion) and the cohesion causes surface tension. This is always trying to collapse the alveolus down (that’s why bubble making solution is soapy … if it was just water, the bubble would collapse on itself too fast)

□

Soap like liquid (detergent) which reduces the surface tension of the mucous that lines the alveoli … □

Type II alveolar cells 

Two types of alveolar cells: ○

1/3 of the recoil property of the lung comes from elastic tissue and 2/3 from the surface tension from the alveoli 

Note: Elastic fibers also help to keep alveoli open. ○

Alveolus •

Really thin … only 0.5um thick ○

Gas goes between alveoli (airway) and blood ○

Diffuse O2 in and CO2 out ○

This glues the two together 

Capillary endothelial cell and type 1 pneumocyte (alveolar cell) share the same basement membrane ○

Gas Exchange Membrane •

Lungs in the thoracic cavity are covered in a thin membrane (1 cell thick) called pleura ○

Parietal lines the thoracic wall □

Visceral lines the lungs □

Parietal and Visceral Pleura 

The lungs and thoracic cavity are covered in pleura ○

Between the two layers 

‘Space’ between parietal and visceral pleura 

Serous membrane secretes pleural fluid and is found in the cavity 

Pleural cavity ○

The water molecules within the serous fluid keeps the lungs plastered against the thoracic wall which is useful when breathing in. As you increase the size of the thoracic cage, you want the lung tissue to follow it -- therefore you rely upon the adhesive properties of the water (serous fluid) to bring the lungs along for a ride

□

Negative with respect to the outside atmosphere … sub-atmospheric □

Negative … is a slight vacuum □

If you put air in the cavity, the lung wont follow the thoracic wall = pneumothorax □

Negative pleural pressure (-2 to -6 mmHg) 

Pleural fluid allows lung and thoracic wall to move with little friction AND creates a hydrostatic force (very important!) ○

Pleura •

Pleural Membranes •

Parietal and visceral are actually one continuous membrane 

When primary bronchii form, they develop lung buds at the tips (lung tissue growing into thoracic cavity. At the time the thoracic cavity is lined by parietal pleura. As the buds grow into the cavity, they pull the parietal pleura with them. But now that the parietal pleura is associated with the lung bud, we call it now the visceral pleura. The lung will continue to grow and occupy the thoracic space until you have just a small potential space between the two pleura … which again is one continuous structure

□ Formation 

○

Space heart is occupying □

Cardiac notch 

Makes like an arching impression and then a falling one □

Arch of the aorta and descending aorta 

Impression on the inferior surface of the lung □

Diaphragm 

Left Lung ○

Dumps into the SVC □

Azygous vein 

Very slight impression □

Heart 

More elevated on the right hand side (you have the liver so it elevates the diaphragm) so the notch is slightly elevated □

Diaphragm 

You can identify three lobes and two fissures (rather than two and one for the left side) □

Note:  Right Lung ○

Impressions from the Lungs •

You getting air into and out of your lungs 

Leads to respiration which = doing gas exchange 

Ventilation ○

PV=k 

Pressure x volume = constant 

Ventilation works on Boyles Law ○

Now atmospheric pressure is greater than that in the lungs so this will push air into the lungs □

↑ volume = ↓ pressure 

Pressure inside lungs is higher than atmospheric pressure … causes air to exit □

↓ Decrease volume = ↑ pressure 

Quite simply: ○

Pretty much how easy it is to make your lungs larger □

= Change is related to elastic nature of tissue 

Party balloons … easy to inflate by mouth so it is highly compliant □

Part animal balloons … stiff plastic and cant do by mouth so it is non-compliant □

Ex: balloons 

In any fibrotic disease that causes scar tissue to go down (collagen) which doesn’t stretch well which makes it difficult to inflate the lung

□

Decrease in Compliance 

A decrease in elastic tissue causes compliance to increase □ Note:  Compliance ○ Mechanisms of Ventilation •

Exchange gases between alveoli and blood 

Exchange gases between blood and tissues 

Ability to: ○

Most gas in atm is nitrogen so it gives off most pressure □

Oxygen is low and therefore exerts a small partial pressure □

Each gas in a mixture gives off its own partial pressure □

PP is dependent on the percent that the gas occupies in the environment □

[pressure] x [gas %] = Partial pressure of gas (Pgas) 

Differences in the partial pressure causes the oxygen to move from one medium to another □

Direction of diffusion is determined by partial pressure of the gas. (gas movement from high to low pressure) □

Why is this important? 

Dalton’s Law ○

Mechanisms of Respiration •

Differences in the partial pressure causes the oxygen to move from one medium to another □

Atmosphere: 160mmHg □

Drops from the atm as there is CO2mixing with it and cause we are humidifying the air with water, decreasing the

pressure (as water gives off its own pressure) ◊ Alveolar: 105mmHg (104) □ Arterial blood: 100mmHg (104) □ Tissue: 40mmHg □

(104) cause in a healthy lung, the PP should equilibrate at the level of the alveoli ◊

Note: □

Example for PO2:

□

Diaphragm does much of the work 

Increased thoracic capacity due to downward movement in diaphragm (1-2 cm) ○

Adult = 0.5L of air per inspiration (tidal volume) ○

Atmospheric air pressure = 60 mmHg. 

Intrapulmonary air pressure = 758 mmHG 

This small difference drives the movement of air 

Pressure difference ○

Also use the external intercostals  Note: ○ Quiet Inspiration • Diaphragm (8-10cm) ○

Bring ribs up and out 

External Intercostals ○

Help fix upper portion of the thoracic cage 

Works with the external intercostals 

Muscles that fix upper ribs (Scalenes, Sternocleidomastoid) ○

Remember its that hydrostatic force caused by the serous fluid 

Hydrostatic force created by the pleural fluid allows lungs to move with the thoracic wall and diaphragm. ○

Not the diaphragm as the innervation is C3,4,5 and therefore it would be referred pain to the neck (dermatomes of 3,4,5 corre spond to that)



Its actually from the intercostal muscles which have segmental innervation 

Where does a stich originate from? ○

Forced Inspiration •

Diaphragm doesn’t have much room to move … that 1-2cm is pretty max 

Pregnancy ○

Food is filling the stomach … which sits under left border of diaphragm  Eat lots ○ Corset ○ … ○

Hard to Breathe When … •

Elastic recoil of lungs and musculature (relaxes) 

Quiet Expiration ○

Internal intercostal muscles (contract) 

Abdominal wall musculature (compress viscera) 

Muscles that fix inferior ribs (e.g. Quadratus lumborum) 

Forced Expiration ○

Expiration •

Anatomy □

Mechanics □

Movement of air into and out of lungs 

Ventilation ○

Exchange of gases (O2 and CO2) 

Tissue □

Between tissue and blood □

Between blood and lungs □

Happens at 

By definition includes ventilation 

Respiration ○

Definitions •

Refers to O2 utilization and CO2 production by metabolizing tissues

In document Departamento de Aduanas e Impuestos Especiales 3. IMPUESTOS SOBRE EL ALCOHOL Y BEBIDAS ALCOHÓLICAS (página 48-51)