Trachea
The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all animals' lungs. The trachea extends from the larynx and branches into the two primary bronchi. At the top of the trachea, the cricoid cartilage attaches it to the larynx. The trachea is formed by a number of horseshoe-shaped rings, joined together vertically by overlying ligaments, and by the trachealis muscle at their ends. The epiglottis closes the opening to the larynx during swallowing.
The trachea begins to form in the second month of embryo development, becoming longer and more fixed in its position over time. Its epithelium is lined with column-shaped cells that have hair-like extensions called cilia, with scattered goblet cells that produce protective mucins. The trachea can be affected by inflammation or infection, usually as a result of a viral illness affecting other parts of the respiratory tract, such as the larynx and bronchi, called croup, that can result in a cough. Infection with bacteria usually affects the trachea only and can cause narrowing or even obstruction. As a major part of the respiratory tract, the trachea, when obstructed, prevents air from entering the lungs; thus, a tracheostomy may be required. Additionally, during surgery, if mechanical ventilation is required during anaesthesia, a tube is inserted into the trachea: this is called tracheal intubation.
In insects, the word trachea is used for a very different organ than in vertebrates. The respiratory system of insects consists of spiracles, tracheae, and tracheoles, which together transport metabolic gases to and from tissues.
Structure
An adult's trachea has an inner diameter of about and a length of about, wider in males than females. The trachea begins at the lower edge of the cricoid cartilage of the larynx at the level of sixth cervical vertebra and ends at the carina, the point where the trachea branches into left and right main bronchi., at the level of the fourth thoracic vertebra, although its position may change with breathing. The trachea is surrounded by 16–20 rings of hyaline cartilage; these 'rings' are 4 millimetres high in the adult, incomplete and C-shaped. Ligaments connect the rings. The trachealis muscle connects the ends of the incomplete rings and runs along the back wall of the trachea. Also adventitia, which is the outermost layer of connective tissue that surrounds the hyaline cartilage, contributes to the trachea's ability to bend and stretch with movement.Although trachea is a midline structure, it can be displaced normally to the right by the aortic arch.
Nearby structures
The trachea passes by many structures of the neck and chest along its course.In front of the upper trachea lies connective tissue and skin. Several other structures pass over or sit on the trachea; the jugular arch, which joins the two anterior jugular veins, sits in front of the upper part of the trachea. The sternohyoid and sternothyroid muscles stretch along its length. The thyroid gland also stretches across the upper trachea, with the isthmus overlying the second to fourth rings, and the lobes stretching to the level of the fifth or sixth cartilage. The blood vessels of the thyroid rest on the trachea next to the isthmus; superior thyroid arteries join just above it, and the inferior thyroid veins below it. In front of the lower trachea lies the manubrium of the sternum, the remnants of the thymus in adults. To the front left lie the large blood vessels the aortic arch and its branches the left common carotid artery and the brachiocephalic trunk; and the left brachiocephalic vein. The deep cardiac plexus and lymph nodes are also positioned in front of the lower trachea.
Behind the trachea, along its length, sits the oesophagus, followed by connective tissue and the vertebral column. To its sides run the carotid arteries and inferior thyroid arteries; and to its sides on its back surface run the recurrent laryngeal nerves in the upper trachea, and the vagus nerves in the lower trachea.
The trachealis muscle contracts during coughing, reducing the size of the lumen of the trachea.
Blood and lymphatic supply
The upper part of trachea receives and drains blood through the inferior thyroid arteries and veins; the lower trachea receives blood from bronchial arteries. Arteries that supply the trachea do so via small branches that supply the trachea from the sides. As the branches approach the wall of the trachea, they split into inferior and superior branches, which join with the branches of the arteries above and below; these then split into branches that supply the anterior and posterior parts of the trachea. The inferior thyroid arteries arise just below the isthmus of the thyroid, which sits atop the trachea. These arteries join with ascending branches of the bronchial arteries, which are direct branches from the aorta, to supply blood to the trachea. The lymphatic vessels of the trachea drain into the pretracheal nodes that lie in front of the trachea, and paratracheal lymph nodes that lie beside it.Development
In the fourth week of development of the human embryo as the respiratory bud grows, the trachea separates from the foregut through the formation of ridges which eventually separate the trachea from the oesophagus, the tracheoesophageal septum. This separates the future trachea from the oesophagus and divides the foregut tube into the laryngotracheal tube. By the start of the fifth week, the left and right main bronchi have begun to form, initially as buds at the terminal end of the trachea.The trachea is no more than 4 mm in diameter during the first year of life, expanding to its adult diameter of approximately 2 cm by late childhood. The trachea is more circular and more vertical in children compared to adults, varies more in size, and also varies more in its position in relation to its surrounding structures.
Microanatomy
The trachea is lined with a layer of interspersed layers of column-shaped cells with cilia. The epithelium contains goblet cells, which are glandular, column-shaped cells that produce mucins, the main component of mucus. Mucus helps to moisten and protect the airways. Mucus lines the ciliated cells of the trachea to trap inhaled foreign particles that the cilia then waft upward toward the larynx and then the pharynx where it can be either swallowed into the stomach or expelled as phlegm. This self-clearing mechanism is termed mucociliary clearance. Directly beneath this mucus layer lies the submucosa layer which is composed primarily of fibrous connective tissue and connects the mucosa to the rings of hyaline cartilage beneath.The trachea is surrounded by 16 to 20 rings of hyaline cartilage; these 'rings' are incomplete and C-shaped. Two or more of the cartilages often unite, partially or completely, and they are sometimes bifurcated at their extremities. The rings are generally highly elastic but they may calcify with age.
Function
The trachea's main function is to transport air to and from the lungs. It also helps to warm, humidify, and filter the air before it reaches the lungs.The trachea is made up of rings of cartilage, which help to keep it open and prevent it from collapsing. The inside of the trachea is lined with a mucous membrane, which produces mucus to help trap dirt and dust particles. The cilia, which are tiny hairs that line the mucous membrane, help to move the mucus and trapped particles up and out of the trachea.
Clinical significance
Inflammation and infection
of the trachea is known as tracheitis, usually due to an infection. It is usually caused by viral infections, with bacterial infections occurring almost entirely in children. Most commonly, infections occur with inflammation of other parts of the respiratory tract, such as the larynx and bronchi, known as croup, however bacterial infections may also affect the trachea alone, although they are often associated with a recent viral infection. Viruses that cause croup are generally the parainfluenza viruses 1–3, with influenza viruses A and B also causing croup, but usually causing more serious infections; bacteria may also cause croup and include Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. Causes of bacterial infection of the trachea are most commonly Staphylococcus aureus and Streptococcus pneumoniae. In patients who are in hospital, additional bacteria that may cause tracheitis include Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa.A person affected with tracheitis may start with symptoms that suggest an upper respiratory tract infection such as a cough, sore throat, or coryzal symptoms such as a runny nose. Fevers may develop and an affected child may develop difficulty breathing and sepsis. Swelling of the airway can cause narrowing of the airway, causing a hoarse breathing sound called stridor, or even cause complete blockage. Up to 80% of people affected by bacterial tracheitis require the use of mechanical ventilation, and treatment may include endoscopy for the purposes of acquiring microbiological specimens for culture and sensitivity, as well as removal of any dead tissue associated with the infection. Treatment in such situations usually includes antibiotics.
Narrowing
A trachea may be narrowed or compressed, usually a result of enlarged nearby lymph nodes; cancers of the trachea or nearby structures; large thyroid goitres; or rarely as a result of other processes such as unusually swollen blood vessels. Scarring from tracheobronchial injury or intubation; or inflammation associated with granulomatosis with polyangiitis may also cause a narrowing of the trachea. Obstruction invariably causes a harsh breathing sound known as stridor. A camera inserted via the mouth down into the trachea, called bronchoscopy, may be performed to investigate the cause of an obstruction. Management of obstructions depends on the cause. Obstructions as a result of malignancy may be managed with surgery, chemotherapy or radiotherapy. A stent may be inserted over the obstruction. Benign lesions, such as narrowing resulting from scarring, are likely to be surgically excised.One cause of narrowing is tracheomalacia, which is the tendency for the trachea to collapse when there is increased external pressure, such as when airflow is increased during breathing in or out, due to decreased compliance. It can be due to congenital causes, or due to things that develop after birth, such as compression from nearby masses or swelling, or trauma. Congenital tracheomalacia can occur by itself or in association with other abnormalities such as bronchomalacia or laryngomalacia, and abnormal connections between the trachea and the oesophagus, amongst others. Congenital tracheomalacia often improves without specific intervention; when required, interventions may include beta agonists and muscarinic agonists, which enhance the tone of the smooth muscle surrounding the trachea; positive pressure ventilation, or surgery, which may include the placement of a stent, or the removal of the affected part of the trachea. In dogs, particularly miniature dogs and toy dogs, tracheomalacia, as well as bronchomalacia, can lead to tracheal collapse, which often presents with a honking goose-like cough.