Anatomy of lung, pleura, surface

marking, Named signs in RS

 Surface marking - Pleura
• Cervical – curved line forming a dome over the
medial 1/3rd of clavicle with height of 2.5cm over
the bone
• Anterior margin – costomediastinal line of pleural
reflection
– Right – sternoclavicular joint, downwards and
medially to the midpoint of the sternal angle,
vertically down to lower end of sternum (or xiphoid)
– Left – same course upto 4th costal cartilage, arches
outwards, descends along sternal margin upto 6th CC
• Inferior margin – costodiaphragmatic line of pleural
reflection
– From lower limit of anterior margin
– 8th rib at MCL
– 10th rib in MAL
– 12th rib at lateral border of sacrospinalis (scapular line)
– Passes horizontally to lower border of T12 vertebra (2cm
lateral to the spine) – behind upper pole of kidneys
• Posterior margin – 2cm lateral to spine – T7 to T12
• Closely lines lung except lower margin
– Anteriorly 4-5 cm below lower border of lung
– Posteriorly 9-10 cm
 Surface marking – lung
• Apex – coincides with cervical pleura
– Kronig’s isthmus (Supraclavicular region) – band of
resonance 5-7cm
• Medial – scalene
• Lateral – Acromion process of scapula
• Anterior – clavicle
• Posterior – Trapezius
• Impaired/dull – upper lobe collapse, fibrosis, mass
• Hyperresonant – Pneumothorax, emphysema
• Anteriorly
– Sternoclavicular joint
– Median plane at sternal angle
– Median plane above the xiphisternal joint
– Left – At level of 4th CC, passes laterally for 3.5cm
and curves dowwards to stop 4cm lateral to medical
plane – cardiac notch or area of superfical cardiac
percussion (dull)
• Inferior – 2 ribs higher than pleural reflection
– 6th rib at MCL, 8th rib at MAL, 10th rib at lateral
border of erector spinae, ends 2cm lat to T10 spine
 Fissures
• Oblique
– T2 spine along the medial border of scapula with
arm in hyperabduction
– 5th rib in the MAL
– 6th CC junction
• Horizontal
– Horizontal line drawn fro m4th CC junction to
meet the oblique fissure
 Bronchopulmonary segments
• Well-defined sectors of the lung, each of which is
aerated by one tertiary bronchus
• Pyramidal shape with apex towards root of lung
• Surrounded by connective tissue septa –
continuous on the surface with pleura
• Independent respiratory units
• Each segment – own pulmonary Artery –
dorsolateral to bronchus

Principal bronchi → secondary lobar bronchi (3 – right, 2 – left) → segmental/tertiary

bronchi (10 on each side) → terminal bronchioles → respiratory bronchioles → Pulm unit
• Pulmonary Veins – run in the connective
tissue septa between segments
– Each segment – more than one Pulm vein
– One Pulm vein – drains more than one segment
– Dissect along veins in segmental resection
– Not a bronchovascular segment – dose not have
its own vein
• Limits the spread of infection – septae
 Nerve supply
• Parietal pleura – pain sensitive
– Somatic sensation through intercostal and phrenic
nerves
• Visceral – not pain sensitive
• Sympathetic – T2-T5
• Parasympathetic – vagus
 Lymphatic drainage
• Parietal pleural – axillary nodes
• Right lung and left lower lobe – right
supraclavicular nodes
• Left upper lobe – left supraclavicular node
 Eponymous signs in RS
• Trail sign – prominence of SCM on side of tracheal shift
– Pretracheal fascia enclosing clavicular head relaxes
• D’Espine’s sign – tubular BBS and whispering
pectoriloquy over thoracic spine below T3 in adults (T4
in children)
– Transmission of through mass in middle or posterior
mediatinum
• Pemberton’s sign – bilateral arm elevation causes facial
plethora f/b cyanosis and respiratory distress
– Thoracic inlet ‘corked off’ by thyroid
– SVC syndrome, substernal goitre, mediastinal and upper
lobe lung masses
• Litten sign
– Diaphragm movement can sometimes be seen with inspiration as a
flickering along the lateral chest. A loss of this movement on one side
indicates a paralyzed hemidiaphragm
• Duchenne's sign
– Epigastric depression with inspiration suggests large pericardial
effusion or a paralyzed diaphragm
• Jackson's breathing sign
– With hemiplegia, the affected side moves more than the unaffected
side during quiet respiration but becomes more sluggish with forced
respiration
• Broadbent’s sign
– Focal retractions suggests bronchial obstruction, flail chest, or
constrictive pericarditis
• Hoover’s sign
– Paradoxic closing of the costal angle with inspiration because of the
loss of intercostal contribution secondary to air trapping. This sign
indicates chronic obstruction and an FEV1 less than 1 liter per second
• Bird’s sign
– Dullness to percussion plus absent breath sounds caused by hydatid
disease in the lungs
• Dahl’s sign
– Calluses on the extensor surface of the forearm or distal thigh in
COPD
• Ewart’s sign
– Dullness below left scapula (right – Conner’s sign)
– Large pericardiual effusion
• Grocco’s triangle
– Triangular area of dullness at base of lung near spinous
processes – side opp to pleural effusion
• Pleural effusion may be suggested by the following:
– Increased rib vibration in the anterior chest to percussion
posteriorly (Kellock's sign)
– Change in the percussible dullness with change in position
(D'Amato's sign)
– Hyperresonance just above an area of dullness (skodaic hyper-
resonance)
• Lombardi's sign of tuberculosis
– Varicosities over the C7-T3 spinous processes
• A change to a goat-like "a" sound after saying "e" in the area of
dullness suggests consolidation (Shibley's sign). Egophony -- either "e"
to "a" or "u" to "a" (Karplus' sign) -- just above an area of dullness
suggests pleural effusion
• Bethea’s sign
– Decreased rib expansion can be caused by an inflammatory process in the
lungs
• Andral's decubitus sign
– With pleuritic inflammation, the patient will lie with the good side down
• Schepelmann's sign
– Chest pain that increases with bending toward the pain suggests intercostal
neuralgia; increase in pain bending away from the pain suggests pleuritic pain
• Perez's sign
– A sternal friction rub heard when the patient raises and lowers the arms
suggests aortic arch aneurysm or fibrotic mediastinal tumor
• Shephard's Sign of Sleep Apnea
– In some patients with sleep apnea, a sonorous expiratory wheeze will develop
at the base of the neck.
 PE
• Hampton’s hump is a shallow, wedge-shaped
opacity in the periphery of the lung, with its base
against the pleural surface
• Westermark’s sign is the demonstration of a
sharp cut-off of pulmonary vessels with distal
hypoperfusion in a segmental distribution within
the lung
• Palla’s signs is Enlargement of right descending PA
(sausage shaped appearance of the vessel)
• McConnell’s sign is Regional wall motion
abnormalities that spare the right ventricular
apex