LIVING ANATOMY:

IMPLICATIONS OF

RESPIRATION

CONVOCATION

MARCH 16, 2019

PAMELA L. WILSON, D.O.

“I believe you are taught anatomy in our school more thoroughly than any other school to date, because we want you to carry a living picture of all or any part of the body in your mind….”

Andrew Taylor Still, MD,DO

RESPIRATORY VOLUME CURVE

ELASTIC RECOIL

TENSION PTX

CHEST WALL

Semi-rigid cylinder

Allows body movement

Protects organs

Prevents tissue collapse during pressure gradient development within thoracic cavity

Anchor against which diaphragm can work

THORACIC CAGE

Ribs, spine, sternum, costal cartilage

105 articulations

–Costovertebral

–Costotransverse

–Costochondral

–Chondrosternal

–Sternomanubrial

– facet

BONEY THORAX

Ribs

spine

sternum

Costal cartilage

COSTOVERTEBRAL JOINTS

Ribs 2-11 articulate with two vertebral bodies and the intervertebral disc

Each rib articulates with the transverse process of a vertebrae

COSTAL CARTILAGE

STERNUM

STERNUM

STERNUM

STERNUM

SCALENES

Initiate respiration

Anterior, middle, posterior

Origin: transverse process C3 –C7

Insertion: ribs 1 and 2

TRANSVERSUS ABDOMINIS

Exhalation

Fibers horizontally oriented, like a belt

Origin:

– inner surface cartilage last six ribs

– Thoracolumbar fascia

– Iliac crest / inguinal ligament

Insertion:

– Rectus aponeurosis

EXTERNAL OBLIQUE

ABDOMINIS

Exhalation

Origin: lateral boarders of lower eight ribs

Insertion: rectus aponeurosis, anterior iliac crest

Fibers oriented diagonally downward

INTERNAL OBLIQUE

ABDOMINIS

Exhalation

Origin: cartilage lower three ribs, rectus aponeurosis

Insertion: iliac crest and inguinal ligament

Fibers run diagonally upward

QUADRATUS LUMBORUM

Inserts on 12th rib

Transverse process of L1-L4

Iliac crest

Lateral to psoas

Complex muscle:

-vertical fibers

-2 sets of oblique fibers

Acts against upward pull of diaphragm on12th rib

Holds 12th rib down

Activates in response to diaphragm, after beginning of inspiration

DIAPHRAGM

Primary muscle of respiration

Separates abdomen and thorax

Allows abdominal contents to function like a piston

DIAPHRAGM

Global influence on body:

– Muscles of mouth, pharynx

– Abdominal and thoracic organ motion

– Postural effects

– Has continuous anterior and posterior fascial connections with pelvis and skull

DIAPHRAGM

Central tendon

– Flexible aponeurosis designed to resist pulling forces

– Attachment site for muscle fibers

Hiatus for Inferior vena cava

Anterior attachment to pericardium

DIAPHRAGM

Costal fibers Innervation: Phrenic

nerves (2) Origin: central tendon

– Shortest anteriorly – Longest posteriorly

Insertion: Sternum, Inner surface lower six ribs, Posterior arcuate ligament, – 12th rib – Psoas – Quadratus lumborum

DIAPHRAGM

Crural fibers

– Pillars of diaphragm

– Derivative dorsal esophageal mesentery

Innervation: Vagus

Hiatus:

– Aorta

– esophagus

Insert on L3 to L4 vertebrae

DIAPHRAGM POWER

DIAPHRAGM POWER

DIAPHRAGM POWER

ABDOMINAL ORGANS

SUSPENDED FROM SPINE

MOTION IMPORTANT FOR

CANCER TREATMENT Tumors decrease

motion of tissue

Respiration moves tumor in and out of treatment field

Must decrease dose to tumor to prevent damage to healthy tissue

RESPIRATORY MOTION

Inhalation moves abdominal organs

–Superior Inferior

–Posterior Anterior

HYSTERESIS

Organ does not exactly retrace its path during a respiratory cycle

INSPIRATORY EFFECT ON

KIDNEY MOTION [15]

ORGAN HYSTERESIS [12]

ORGAN HYSTERESIS [12]

ORGAN HYSTERESIS [12]

AVERAGE ORGAN MOTION

4-D CT: superior/inferior [12]

LIVER

–1.3 cm

SPLEEN

–1.3 cm

RIGHT KIDNEY

–1.3 cm

LEFT KIDNEY

–1.1 cm

KIDNEY LESIONS

ULTRASOUND EVALUATION

[15]

Normal / Right: Left:

less than 1 cm: 2.5cm 1.8cm

Lesion 1-2 cm: 2.3cm 1.5cm

Lesion 2+ cm: 1.9cm 1.3cm

“Keep your minds full of pictures of the normal body all the time while treating the afflicted”

Andrew Taylor Still, MD, DO

REFERENCES: 1. Willard, F. Foundations of Osteopathic Medicine, 3rd ed. 2011;

Lippincott, Williams and Wilkins; pg 206-220.

2. A.T. Still, Philosophy of Osteopathy; 1899, 4th reprint, AAO

3. Blandine, C. Anatomy of Breathing, Eastland press, 2006

4. Barral, J.P. The Thorax, Eastland Press, 1991

5. Barral, J.P. Visceral Manipulation, Eastland Press, 1988

6. Bordoni, B., Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidisp Health. 2013:6 281-291

7. McCool, F.D., Dysfunction of the Diaphragm, N Engl J Med 2012;366: 932-42

8. De Troyer, A., Functional Anatomy of the Respiratory Muscles, Clinics in Chest Medicine-Vol 9, No 2 June 1988

9. Cappello, M. On the respiratory function of the ribs, J Appl Physiol 92: 1642-1646, 2002

10. Kenyon: Rib cage mechanics during quiet breathing and exercise in humans; J Appl Physiol 83(4): 1242-1255, 1997

11. Ingber, D.E. The Architecture of Life, Scientific American, 1998, 278:48-57

REFERENCES

12. Brandner, E.D.; 2006. Abdominal organ motion measured using 4D CT; Int. J. Radiation Oncology and Biol. Phys., Vol. 65,No.2, pp. 554-560.

13. Boyd, W., Sequence of action of the Diaphragm and quadratus lumborium during quiet breathing.; Anat. Rec., 151: 579-582.

14. Chiti, L., Scalene muscle activity during progressive inspiratory loading under pressure support ventilation. Respiratory Physiology & Neurobiology 164(2008), 441-448.

15. Rakkuneeth, H., Quantitative study on the effect of abnormalities on respiration-induced kidney movement. Ultrasound in Medicine & Biol., Vol.42, No. 7, pp. 1681-1688,2016

16. Chuhan,C. The lymphatic vascular system in liver diseases: its roke in ascites formation. Clinical and Molecular Hepatology, 2013: 19 :99-104