Pleura, lungs, trachea and bronchi

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CHAPTER 57 Pleura, lungs, trachea and bronchi

The lungs are the essential organs of respiration and are responsible for the uptake of oxygen into the blood and the removal of carbon dioxide. The functional design of the thorax facilitates this complex process. The muscles of respiration and the diaphragm, acting together, increase the intrathoracic volume, creating a negative pressure within the pleural space which surrounds the lung and causing expansion of the lung (see Ch. 58). The resultant reduction in intra-alveolar pressure prompts the conduction of air through the upper respiratory tract into the trachea and airways and thence into the alveoli, where gaseous exchange occurs. The process of breathing exposes the lung to noxious agents, including gases, dust particles, bacteria and viruses; the mucous barrier, mucociliary escalator, branching pattern of the airways and the cough reflex are all anatomical defences against these insults. Anatomical defects may compromise respiratory function; for example, chest wall abnormalities may cause restrictive lung disease. Similarly, ultrastructural abnormalities such as ciliary dysfunction (as seen in Kartagener’s syndrome) lead to recurrent respiratory infections and airway damage.

PLEURA

Each lung is covered by pleura, a serous membrane arranged as a closed invaginated sac. The visceral or pulmonary pleura adheres closely to the pulmonary surface and its interlobar fissures. Its continuation, the parietal pleura, lines the corresponding half of the thoracic wall and covers much of the diaphragm and structures occupying the middle region of the thorax. The visceral and parietal pleurae are continuous with each other around the hilar structures, and they remain in close, though sliding, contact at all phases of respiration. The potential space between them is the pleural cavity, which is maintained at a negative pressure by the inward elastic recoil of the lung and the outward pull of the chest wall.

The right and left pleural sacs form separate compartments and touch only behind the upper half of the sternal body (see Fig. 53.6A,B), although they are also close to each other behind the oesophagus at the midthoracic level. The region between them is the mediastinum (interpleural space). The left pleural cavity is the smaller of the two, because the heart extends further to the left. The upper and lower limits of the pleurae are about the same on the two sides, but the left sometimes descends lower in the midaxillary line.

The interlobar fissures and posterior azygo-oesophageal and retrosternal pleural reflections are the only aspects of the normal pleura that can be visualized on a chest radiograph or CT scan (Fig. 57.1A–D; see Figs 55.16, 55.17). Demonstration of significant pleural shadowing in any other regions usually implies pathological abnormalities of the pleura. Thoracoscopy allows the direct inspection of both the parietal and visceral surfaces. The parietal pleura is translucent and at thoracoscopy the underlying muscles and blood vessels are visible. The visceral pleura is also translucent and has a grey variegated appearance due to the underlying lung and the vascular network in the subpleural layer.

PARIETAL PLEURA

Different regions of parietal pleura are customarily distinguished by name, thus the costovertebral pleura lines the internal surface of the thoracic wall and the vertebral bodies, the diaphragmatic pleura lies on the thoracic surface of the diaphragm, the cervical pleura lies over the pulmonary apices (and is therefore also called the dome of the pleura), and the mediastinal pleura is applied to the structures between the lungs.

Costovertebral pleura

Costovertebral pleura lines the sternum, ribs, transversus thoracis and intercostal muscles and the sides of the vertebral bodies; normally it is easily separated from these structures. External to the pleura is a thin layer of loose connective tissue, the endothoracic fascia, which corresponds to the transversalis fascia of the abdominal wall. Anteriorly, the costal pleura begins behind the sternum, where it is continuous with the mediastinal pleura along a junction extending from behind the sternoclavicular joint down and medially to the midline behind the sternal angle. From here, the right and left costal pleurae descend in contact with each other to the level of the fourth costal cartilages and then diverge. On the right side, the line descends to the back of the xiphisternal joint, while on the left the line diverges laterally and descends at a distance of 2–2.5 mm from the sternal margin to the sixth costal cartilage, forming the cardiac notch. On each side, the costal pleura sweeps laterally, lining the internal surfaces of the costal cartilages, ribs, transversus thoracis and intercostal muscles. Posteriorly, it passes over the sympathetic trunk and its branches to reach the sides of the vertebral bodies, where it is again continuous with the mediastinal pleura. The costovertebral pleura is continuous with the cervical pleura at the inner margin of the first rib and below it becomes continuous with the diaphragmatic pleura along a line which differs slightly on the two sides. On the right, this line of costodiaphragmatic reflection begins behind the xiphoid process, passes behind the seventh costal cartilage to reach the eighth rib in the midclavicular line, the tenth rib in the midaxillary line, and then ascends slightly to cross the twelfth rib level with the upper border of the twelfth thoracic spine (see Fig. 53.6A,B). On the left, the line initially follows the ascending part of the sixth costal cartilage, but then follows a course similar to that on the right, although it may be slightly lower.

Cervical pleura

The cervical pleura is a continuation of the costovertebral pleura over the pulmonary apex (Fig. 57.2). It ascends medially from the internal border of the first rib to the apex of the lung, as high as the lower edge of the neck of the first rib, and then descends lateral to the trachea to become the mediastinal pleura. As a result of the obliquity of the first rib, the cervical pleura extends 3–4 cm above the first costal cartilage, but not above the neck of the first rib. The cervical pleura is strengthened by a fascial suprapleural membrane, which is attached in front to the internal border of the first rib, and behind to the anterior border of the transverse process of the seventh cervical vertebra. It contains a few muscular fibres, which spread from the scaleni. Scalenus minimus extends from the anterior border of the transverse process of the seventh cervical vertebra to the inner border of the first rib behind its subclavian groove, and also spreads into the pleural dome, which it therefore tenses: it has been suggested that the suprapleural membrane is the tendon of scalenus medius. The cervical pleura (like the pulmonary apex) reaches the level of the seventh cervical spine approximately 2.5 cm from the midline. Its projection is a curved line from the sternoclavicular joint to the junction of the medial and middle thirds of the clavicle, its summit being 2.5 cm above it. The subclavian artery ascends laterally in a furrow below the summit of the cervical pleura (Fig. 57.2).

PLEURAL RECESSES

The pleura extends considerably beyond the inferior border of the lung, but not as far as the attachment of the diaphragm, which means that the diaphragm is in contact with the costal cartilages and intercostal muscles below the line of pleural reflection from the thoracic wall to the diaphragm. In quiet inspiration the inferior margin of the lung does not reach this reflection, and the costal and diaphragmatic pleurae are separated merely by a narrow slit, the costodiaphragmatic recess. In quiet inspiration the lower limit of the lung is normally 5 cm above the lower pleural limit. A similar costomediastinal recess exists behind the sternum and the costal cartilages, where the thin anterior margin of the lung falls short of the line of pleural reflection. The extent of this recess, the anterior costomediastinal line of pleural reflection, and the position of the anterior margin of the lung all exhibit individual variation.

The inferior border of the right costodiaphragmatic recess is an important consideration in the surgical posterior approach to the kidney. Usually the pleura crosses the twelfth rib at the lateral border of erector spinae, so that the medial region of the kidney is above the pleural reflection (see Fig. 53.6B). However, if the twelfth rib does not project beyond the muscle, the eleventh rib may be mistaken for the twelfth in palpation, and an incision prolonged to this level will damage the pleura. Whether the lowest palpable rib is the eleventh or twelfth can be ascertained by counting from the second rib (identified at its junction with the sternal angle).

VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

The parietal and visceral pleurae are developed from somatopleural and splanchnopleural layers of the lateral plate mesoderm respectively, which means that the parietal pleura is supplied by arteries from somatic sources. The costovertebral pleura is supplied by branches of intercostal and internal thoracic arteries; the mediastinal pleura is supplied by branches from bronchial, upper diaphragmatic, internal thoracic and mediastinal arteries; the cervical pleura is supplied by branches from the subclavian artery; and the diaphragmatic pleura is supplied by the superficial part of the microcirculation of the diaphragmatic muscle. The veins join systemic veins in the thoracic wall which drain into the superior vena cava. Lymph from the costovertebral parietal pleura drains into the internal thoracic chain anteriorly and intercostal chains posteriorly, while that from the diaphragmatic pleura drains into the mediastinal, retrosternal and coeliac axis nodes.

The visceral pleura forms an integral part of the lung and accordingly its arterial supply and venous drainage are provided by the bronchial vessels. The bronchial arteries at the hilum form an anulus that surrounds the main bronchus, and pleural branches from this anulus supply the visceral pleura facing the mediastinum, interlobar surfaces, apical surface and part of the diaphragmatic surface. The visceral pleura is drained by pulmonary veins, apart from an area around the hilum that drains into bronchial veins. The lymphatic drainage of the visceral pleura is to the deep pulmonary plexus within the interlobar and peribronchial spaces.

PNEUMOTHORAX

Any breach of the chest wall and parietal pleura or visceral pleura leads to the accumulation of air within the pleural cavity (pneumothorax). Fluid (hydrothorax), blood (haemothorax) and rarely lymph (chylothorax) can also accumulate in this space. Pneumothoraces may occur spontaneously or following trauma (e.g. rib fractures, penetrating injuries from sharp instruments, iatrogenic injury). Significant air in the pleural space is visible on a chest radiograph: there is separation of the parietal and visceral pleurae and an absence of pulmonary vascular markings in the corresponding area. Occasionally, a ball valve-like effect occurs, so that air enters the pleural space during inspiration but cannot escape in expiration. This tension pneumothorax can be life-threatening and should be suspected whenever there are unilateral decreased breath sounds and hyperresonance on percussion, hypotension, jugular venous distension and contralateral tracheal deviation. A tension pneumothorax requires immediate decompression by the insertion of an intercostal drain or wide bore catheter. Fluid collection in the pleural space may be due to congestive cardiac failure, hypoalbuminaemia, inflammatory, infective or neoplastic conditions. A pleural effusion causes obliteration of the costophrenic angle and the diaphragm, and a lateral meniscus is visible on a frontal chest radiograph. Drainage of the fluid and subsequent analysis is required for diagnostic purposes. Where there is a collection of pus (empyema) or blood, pleural drainage is essential for therapeutic purposes. Ultrasonography is useful in assessing the size and characteristics of an effusion, such as the presence of loculation and debris. It may even demonstrate underlying consolidated lung. Computed tomography is utilized to assess the underlying hidden lung parenchyma and mediastinal glands. For further review of the radiology of the pleurae and lungs, see Armstrong (2000).

LUNGS

The lungs are the essential organs of respiration. They are situated on either side of the heart and other mediastinal contents (Figs 57.3, 57.4). Each lung is free in its pleural cavity, except for its attachment to the heart and trachea at the hilum and pulmonary ligament respectively. When removed from the thorax, a fresh lung is spongy, can float in water, and crepitates when handled, because of the air within its alveoli. It is also highly elastic and so it retracts on removal from the thorax. Its surface is smooth and shiny and is separated by fine, dark lines into numerous small polyhedral domains, each crossed by numerous finer lines, indicating the areas of contact between its most peripheral lobules and the pleural surface.

At birth the lungs are pink, but in adults they are dark grey and patchily mottled. As age advances, this maculation becomes black, as granules of inhaled carbonaceous material are deposited in the loose connective tissue near the lung surface. Darkening is often more marked in men than women, in those who have dwelt in industrial areas and in smokers. The posterior pulmonary border is usually darker than the anterior. In the upper, less movable parts of the lung, this surface pigmentation tends to be concentrated opposite the intercostal spaces. Lungs from fetuses or stillborn infants who have not respired differ from those of infants who have taken a breath in that they are firm, non-crepitant and do not float in water.

The adult right lung usually weighs 625 g, and the left 565 g, but the range of wet weights is considerable, not least because it reflects the amount of blood or serous fluid contained within the lungs when weighed. In proportion to body stature, the lungs are heavier in men than in women.

PULMONARY SURFACE FEATURES

Each lung has an apex, base, three borders and two surfaces (Figs 57.3, 57.4). In shape, each lung approximates to half a cone.

Apex

The apex, the rounded upper extremity, protrudes above the thoracic inlet where it contacts the cervical pleura, and is covered in turn by the suprapleural membrane. As a consequence of the obliquity of the inlet, the apex rises 3–4 cm above the level of the first costal cartilage; it is level posteriorly with the neck of the first rib. Its summit is 2.5 cm above the medial third of the clavicle. The apex is therefore in the root of the neck (see Fig. 35.5A). It has been claimed that, because the apex does not rise above the neck of the first rib, it is really intrathoracic, and that it is the anterior surface that ascends highest in inspiration. The subclavian artery arches up and laterally over the suprapleural membrane, grooves the anterior surface of the apex near its summit and separates it from scalenus anterior. The cervicothoracic (stellate) sympathetic ganglion, the ventral ramus of the first thoracic spinal nerve and the superior intercostal artery all lie posterior to the apex. Scalenus medius is lateral, the brachiocephalic artery, right brachiocephalic vein and trachea are adjacent to the right medial surface of the lung, and the left subclavian artery and left brachiocephalic vein are adjacent to the left medial surface of the apex of the lung.

Other impressions on the lung surface

In addition to these pulmonary features, cadaveric lungs that have been preserved in situ can show a number of other impressions that indicate their relations with surrounding structures (Figs 57.3, 57.4). On the right lung the cardiac impression is related to the anterior surface of the right auricle, the anterolateral surface of the right atrium and partially to the anterior surface of the right ventricle. The impression ascends anterior to the hilum as a wide groove for the superior vena cava and the terminal portion of the right brachiocephalic vein. Posteriorly this groove is joined by a deep sulcus which arches forwards above the hilum and is occupied by the azygos vein. The right side of the oesophagus makes a shallow vertical groove behind the hilum and the pulmonary ligament. Towards the diaphragm it inclines left and leaves the right lung, and therefore does not reach the lower limit of this surface. Posteroinferiorly the cardiac impression is confluent with a short wide groove adapted to the inferior vena cava. Between the apex and the groove for the azygos, the trachea and right vagus are close to the lung, but do not mark it.

On the left lung (Fig. 57.4) the cardiac impression is related to the anterior and lateral surfaces of the left ventricle and auricle. The anterior infundibular surface and adjoining part of the right ventricle is also related to the lung as it ascends in front of the hilum to accommodate the pulmonary trunk. A large groove arches over the hilum, and descends behind it and the pulmonary ligament, corresponding to the aortic arch and descending aorta. From its summit a narrower groove ascends to the apex for the left subclavian artery. Behind this, above the aortic groove, the lung is in contact with the thoracic duct and oesophagus. In front of the subclavian groove there is a faint linear depression for the left brachiocephalic vein. Inferiorly, the oesophagus may mould the surface in front of the lower end of the pulmonary ligament.

Pulmonary borders

The inferior border is thin and sharp where it separates the base from the costal surface and extends into the costodiaphragmatic recess, and is more rounded medially where it divides the base from the mediastinal surface. It corresponds, in quiet respiration, to a line drawn from the lowest point of the anterior border which passes to the sixth rib at about the midclavicular line, then to the eighth rib in the midaxillary line (usually 10 cm above the costal margin), and then continues posteriorly, medially and slightly upwards to a point 2 cm lateral to the tenth thoracic spine (see Fig. 53.5A,B). The diaphragm rises higher on the right to accommodate the liver, and so the right lung is vertically shorter (by approximately 2.5 cm) than the left. However, cardiac asymmetry means that the right lung is broader, and has a greater capacity and weight than the left. The posterior border separates the costal surface from the mediastinal surface, and corresponds to the heads of the ribs. It has no recognizable markings and is really a rounded junction of costal and vertebral (medial) surfaces. The thin, sharp, anterior border overlaps the pericardium. On the right it corresponds closely to the costomediastinal line of pleural reflection, and is almost vertical. On the left it approaches the same line above the fourth costal cartilage; below this point it shows a variable cardiac notch, the edge of which passes laterally for 3.5 cm before curving down and medially to the sixth costal cartilage 4 cm from the midline. It therefore does not reach the line of pleural reflection here (see Fig. 53.5A) and so the pericardium is covered only by a double layer of pleura (area of superficial cardiac dullness). However, surgical experience suggests that the line of pleural reflection, the anterior pulmonary margin and the costomediastinal pleural recess are all variable.

PULMONARY FISSURES AND LOBES

Right lung

The right lung is divided into superior, middle and inferior lobes by an oblique and a horizontal fissure (Fig. 57.3). The upper, oblique fissure separates the inferior from the middle and upper lobes, and corresponds closely to the left oblique fissure, although it is less vertical, and crosses the inferior border of the lung approximately 7.5 cm behind its anterior end. On the posterior border it is either level with the spine of the fourth thoracic vertebra or slightly lower. It descends across the fifth intercostal space and follows the sixth rib to the sixth costochondral junction. The short horizontal fissure separates the superior and middle lobes. It passes from the oblique fissure, near the midaxillary line, horizontally forwards to the anterior border of the lung, level with the sternal end of the fourth costal cartilage, then passes backwards to the hilum on the mediastinal surface. The horizontal fissure is usually visible on a frontal chest radiograph. The oblique fissure is usually visible on a lateral radiograph and on a high resolution CT scan as a curvilinear band from the lateral aspect to the hilum (Fig. 57.1A–D). The small middle lobe is cuneiform and includes some of the costal surface, the lower part of the anterior border and the anterior part of the base of the lung. Sometimes the medial part of the upper lobe is partially separated by a fissure of variable depth which contains the terminal part of the azygos vein, enclosed in the free margin of a mesentery derived from the mediastinal pleura, and forming the ‘lobe of the azygos vein’. This varies in size, and sometimes includes the apex of the lung. It is always supplied by one or more branches of the apical bronchus. Radiographically, a pleural effusion may be limited to the azygos fissure. Less common variations are the presence of an inferior accessory fissure, which separates the medial basal segment from the remainder of the lower lobe, and a superior accessory fissure, which separates the apical segment of the lower lobe from the basal segments. The identification of the completeness of the fissures is important prior to lobectomy, because individuals with incomplete fissures are more prone to develop postoperative air leaks, and may require further procedures such as stapling and pericardial sleeves (see Venuta et al 1998).

Left lung

The left lung is divided into a superior and an inferior lobe by an oblique fissure (Fig. 57.4) which extends from the costal to the medial surfaces of the lung both above and below the hilum. Superficially this fissure begins on the medial surface at the posterosuperior part of the hilum. It ascends obliquely backwards to cross the posterior border of the lung 6 cm below the apex, then descends forwards across the costal surface, to reach the lower border almost at its anterior end. It finally ascends on the medial surface to the lower part of the hilum. At the posterior border of the lung the fissure usually lies opposite a surface point 2 cm lateral to the midline between the spines of the third and fourth thoracic vertebrae, but it may be above or below this level. Traced around the chest, the fissure reaches the fifth intercostal space (at or near the midaxillary line) and follows this to intersect the inferior border of the lung close to, or just below, the sixth costochondral junction (7.5 cm from the midline). The left oblique fissure is usually more vertical than the right, and is indicated approximately by the medial border of the scapula when the arm is fully abducted above the shoulder. A left horizontal fissure is a normal variant found occasionally.

The superior lobe, which lies anterosuperior to the oblique fissure, includes the apex, anterior border, much of the costal and most of the medial surfaces of the lung. At the lower end of the cardiac notch a small process, the lingula, is usually present. The larger inferior lobe lies behind and below the fissure, and contributes almost the whole of the base, much of the costal surface and most of the posterior border of the lung.

Bronchopulmonary segments

Each of the principal bronchi divides into lobar bronchi. Primary branches of the right and left lobar bronchi are termed segmental bronchi because each ramifies in a structurally separate, functionally independent, unit of lung tissue called a bronchopulmonary segment (Figs 57.557.7).

image

Fig. 57.7 The cartilages of the larynx, trachea and bronchi: anterior aspect. The bronchopulmonary segments are shown in brackets.

(Redrawn from an original figure drawn from a metal cast made by the late Lord Russell Brock, GKT School of Medicine, London.)

The main segments are named and numbered as follows:

Right lung
Superior lobe: I, apical; II, posterior; III, anterior
Middle lobe: IV, lateral; V, medial
Inferior lobe: VI, superior (apical); VII, medial basal; VIII, anterior basal; IX, lateral basal; X, posterior basal
Left lung
Superior lobe: I, apical; II, posterior; III, anterior; IV, superior lingular; V, inferior lingular
Inferior lobe: VI, superior (apical); VIII, anterior basal; IX, lateral basal; X, posterior basal

Each segment is surrounded by connective tissue that is continuous with the visceral pleura, and is a separate respiratory unit. The vascular and lymphatic arrangements of the segments are described on pages 996–998.

PULMONARY HILA

The pulmonary root connects the medial surface of the lung to the heart and trachea and is formed by a group of structures which enter or leave the hilum (Figs 57.3, 57.4; see also Fig. 55.4B). These are the principal bronchus, pulmonary artery, two pulmonary veins, bronchial vessels, a pulmonary autonomic plexus, lymph vessels, bronchopulmonary lymph nodes and loose connective tissue, all of which are enveloped by a sleeve of pleura. The pulmonary roots, or pedicles, lie opposite the bodies of the fifth to seventh thoracic vertebrae. The phrenic nerve, pericardiacophrenic artery and vein, and anterior pulmonary plexus are common anterior relations of both hila, and the vagus nerve and posterior pulmonary plexus are common posterior relations. The pulmonary ligament is a common inferior relation. The major structures in both roots are similarly arranged, so that the upper of the two pulmonary veins is anterior, the pulmonary artery and principal bronchus are more posterior, and the bronchial vessels are most posterior. The arrangement of bronchopulmonary segments and the pulmonary hila permit the resection of abscesses and localized lesions caused by lung cancer.

Left hilum

The left root lies below the aortic arch and in front of the descending thoracic aorta. The usual vertical sequence of structures at the left hilum is pulmonary artery, principal bronchus, and lower pulmonary vein (Fig. 57.4). The pulmonary artery is longer on the left side, and each of its branches from the hilum to the oblique fissure must be identified in pulmonary resections.

VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

The lungs have two functionally distinct circulatory pathways. The pulmonary vessels convey deoxygenated blood to the alveolar walls and drain oxygenated blood back to the left side of the heart, and the much smaller bronchial vessels, which are derived from the systemic circulation, provide oxygenated blood to lung tissues that do not have close access to atmospheric oxygen, i.e. those of the bronchi and larger bronchioles.

The pulmonary artery bifurcates into right and left pulmonary arteries which pass to the hila of the lungs. On entering the lung tissue, both arteries divide into branches that accompany segmental and subsegmental bronchi and lie mostly dorsolateral to them. The pulmonary capillaries form plexuses immediately outside the epithelium in the walls and septa of alveoli and alveolar sacs. The plexus forms a single layer in the interalveolar septa, with meshes smaller than the capillaries, and exceedingly thin walls. Pulmonary veins, two from each lung, drain the pulmonary capillaries. Their radicles coalesce into larger branches which traverse the lung independently of the pulmonary arteries and bronchi. Communicating freely, they form large vessels that ultimately accompany the arteries and bronchial tubes to the pulmonary hilum, where the bronchi often separate the dorsolateral artery and the ventromedial vein. The pulmonary veins open into the left atrium and convey oxygenated blood for systemic distribution by the left ventricle.

At the hilum, the pulmonary vessels accompany the main bronchial divisions. This is not the case in the bronchopulmonary segments, where a segmental bronchus, its branches and associated arteries occupy a central position in each segment, but the many tributaries of the pulmonary veins run between segments, serving adjacent segments (which therefore drain into more than one vein). Some veins also lie beneath the visceral pleura, including the pleura in the interlobar fissures. It follows from this that a bronchopulmonary segment is not a complete vascular unit with an individual bronchus, artery and vein. During resection of segments, it is obvious that the planes between them are not avascular but are crossed by pulmonary veins and sometimes by branches of arteries. This pattern of bronchi, arteries and veins exhibits considerable variation: veins are the most variable, and arteries are more variable than bronchi.

Pulmonary arteries

The right pulmonary artery divides into two large branches as it emerges behind the superior vena cava (Fig. 57.8). A lymph node usually occupies the bifurcation. The superior branch, which is the smaller of the two, goes to the superior lobe and usually divides into two further branches, which supply the majority of that lobe. The inferior branch descends anterior to the intermediate bronchus and immediately posterior to the superior pulmonary vein. It provides a small recurrent branch to the superior lobe, then at the point where the horizontal fissure meets the oblique fissure, it gives off the branch to the middle lobe anteriorly, and the branch to the superior segment of the inferior lobe posteriorly. It then continues a short distance before dividing to supply the rest of the inferior lobe segments.

The left pulmonary artery emerges from within the concavity of the aortic arch and descends anterior to the descending aorta to enter the oblique fissure (Fig. 57.8). The branches of the left pulmonary artery are extremely variable. The first and largest branch is usually given off to the anterior segment of the left superior lobe. Before reaching the oblique fissure, the artery gives off a variable number of other branches to the superior lobe, and as it enters the fissure it usually supplies a large branch to the superior segment of the inferior lobe. Lingular branches arise within the fissure, and the rest of the lower lobe is supplied by many varied branching patterns: it was a surgical aphorism of the late Lord Brock that when performing a left upper lobectomy, … ‘there was always one more branch of the pulmonary artery than you thought!’.

Pulmonary veins

There are usually four pulmonary veins, two from each lung. They originate from capillary networks in the alveolar walls and return oxygenated blood to the left atrium. All the main tributaries of the pulmonary veins receive smaller tributaries, both intra- and inter-segmental; by repeated junctions, tributary veins finally form a single trunk in each lobe, i.e. three in the right lung, and two in the left. The right middle and superior lobar veins usually join and so two veins, superior and inferior, leave each lung.

In the pulmonary hilum, the usual distribution of veins is as follows. The superior pulmonary vein is anteroinferior to the pulmonary artery, and the inferior is the most inferior hilar structure and also slightly posterior. On the right, the union of apical, anterior and posterior veins (draining the upper lobe) with a middle lobar vein (formed by lateral and medial tributaries; Fig. 57.8) forms the superior right pulmonary vein. The inferior right pulmonary vein is formed by the hilar union of superior (apical) and common basal veins from the lower lobe. The union of superior and inferior basal tributaries forms the common basal vein. Occasionally the three right lobar veins remain separate. The right superior pulmonary vein passes posterior to the superior vena cava, the inferior behind the right atrium. On the left, the superior left pulmonary vein, which drains the upper lobe, is formed by the union of apicoposterior (draining the apical and posterior segments), anterior and lingular veins (Fig. 57.8). The inferior left pulmonary vein, which drains the lower lobe, is formed by the hilar union of two veins, superior (apical) and common basal, the latter formed by the union of a superior and an inferior basal vein. Both superior and inferior left pulmonary veins pass anterior to the descending thoracic aorta. Sometimes the two left pulmonary veins form a single trunk, or they may be augmented by an accessory lobar vein from each lobe, which unite to form a third left pulmonary vein.

The right and left pulmonary veins perforate the fibrous pericardium and open separately in the posterosuperior aspect of the left atrium (see Figs 56.1, 56.2B). Their terminations are separated centrally by the oblique pericardial sinus, and laterally by smaller and variable pulmonary venous pericardial recesses that are directed medially and upwards. The pulmonary veins are devoid of valves.

INNERVATION

The autonomic nervous system controls many aspects of airway function, including regulation of airway smooth muscle tone, mucus secretion from submucosal glands and surface epithelial goblet cells, vascular permeability and blood flow (see Belvisi 2002).

Pulmonary plexuses

The pulmonary plexuses lie anterior and posterior to the other hilar structures of the lungs (see Fig. 56.20). The anterior plexus is small and is formed by rami from vagal and sympathetic cervical cardiac nerves via connections with the superficial cardiac plexus. The posterior pulmonary plexus is formed by the rami of vagal and sympathetic cardiac branches from the second to fifth or sixth thoracic sympathetic ganglia. The left plexus also receives branches from the left recurrent laryngeal nerve. Further details of the pulmonary plexuses are given in the description of the cardiac plexuses in Chapter 56.

MICROSTRUCTURE OF RESPIRATORY SURFACES

Thin-walled respiratory surfaces (alveoli) are distributed as isolated patches within the walls of respiratory bronchioles, and as tube-like alveolar ducts and balloon-like alveolar sacs which contain groups of adjacent alveoli.

Alveolar structure

The alveoli are thin-walled pouches which provide the respiratory surface for gaseous exchange (Figs 57.957.11). Their walls contain two types of epithelial cell (pneumocytes) and cover a delicate connective tissue within which a network of capillaries ramifies. Since the walls are extremely thin, they present a minimal barrier to gaseous exchange between the atmosphere and the blood in the capillaries. Adjacent alveoli are frequently in close contact and then the intervening connective tissue forms the central part of an interalveolar septum. Alveolar macrophages are present within the alveolar lumen, and migrate over the epithelial surface.

Interalveolar septum

The alveolar lining epithelium varies in thickness, but extensive areas of it are as little as 0.05 μm thick (see Fig. 57.11). The epithelium lies on a basal lamina, which, in the thin portions of a septum, is fused with the basal lamina surrounding the adjacent capillaries. The total barrier to diffusion between air and blood in these thin portions may be as little as 0.2 μm. The thick portions of a septum contain connective tissue elements, including elastic fibres, collagen type III fibres, resident and migratory cells (Fig. 57.10).

Alveolar macrophages

Alveolar macrophages are derived from circulating monocyte precursors. They originate in haemopoietic tissue in the bone marrow, migrate into the alveolar lumen from adjacent blood vessels and connective tissue, and wander about on the epithelial surfaces. They clear the respiratory spaces of inhaled particles which are small enough to reach the alveoli (hence their alternative name of ‘dust cells’). Most of them migrate with their phagocytosed load to the bronchioles, where they are swept into the mucociliary rejection current and removed from the lung. Others migrate through the epithelium of the alveoli into the lymphatics which drain the connective tissue of the lung, and so pass into lymphoid tissue around the pulmonary lobules. Under normal conditions alveolar macrophages have a granular cytoplasm because they contain phagocytosed particles: in smokers the particles have a characteristic appearance, and are called tar bodies. When actively phagocytic, macrophages release proteases: if antiproteases (e.g. α1antitrypsin) that are normally present in the alveolar lining are deficient, macrophage activity may damage the lung. Alveolar macrophages are involved in the turnover of surfactant.

Alveolar macrophages can be recovered from sputum, and are of diagnostic importance if they appear abnormal. For instance, whenever erythrocytes leak from pulmonary capillaries, the macrophages that engulf the extravasated cells become brick red, and are detectable in ‘rusty’ sputum. They are typical of congestive heart failure, and often termed heart-failure cells. Macrophages that migrate back into the connective tissue of the lung settle in patches that are visible beneath the visceral pleura, e.g. carbon-filled cells give the lungs a mottled appearance. However, if the inhaled particles are abrasive or chemically active, they may elude macrophage removal and damage the respiratory surface, producing fibrosis and a concomitant reduction in the respiratory area. This occurs in many industrial diseases, e.g. pneumoconiosis, caused by coal dust, or asbestosis, where the long thin fibres of asbestos can cause considerable damage and may trigger fatal mesothelioma in the pleural lining.

TRACHEA AND BRONCHI

The trachea is a tube formed of cartilage and fibromuscular membrane, lined internally by mucosa. The anterolateral portion is made up of incomplete rings of cartilage, and the posterior aspect by a flat muscular wall. It is 10–11 cm long, and descends from the larynx (Fig. 57.7) from the level of the sixth cervical vertebra to the upper border of the fifth thoracic vertebra, where it divides into right and left principal (pulmonary) bronchi. It lies approximately in the sagittal plane, but its point of bifurcation is usually a little to the right. The trachea is mobile and can rapidly alter in length; during deep inspiration, the bifurcation may descend to the level of the sixth thoracic vertebra. Its external transverse diameter is typically 2 cm in adult males, and 1.5 cm in adult females. In children it is smaller, more deeply placed and more mobile. The lumen in live adults has an average transverse diameter of 12 mm, although this increases after death because the smooth muscle making up its posterior aspect relaxes. In the first postnatal year, the tracheal diameter does not exceed 4 mm, while during later childhood its diameter in millimetres is approximately equal to age in years. The transverse shape of the lumen is variable, especially in the later decades of life, and may be round, lunate or flattened. At bronchoscopy the posterior wall of the trachea bulges into the lumen and this is exaggerated in expiration and coughing. The distal end of the trachea is visible as a concave spur. A tracheal bronchus may occasionally arise from the lateral wall of the trachea, more frequently from the right side: it may be supernumerary or it may represent a displaced upper lobe airway.

TRACHEAL RELATIONS

RIGHT MAIN BRONCHUS

The right principal bronchus is approximately 2.5 cm long, and is wider, shorter and more vertical than the left (Figs 57.7, 57.8, 57.12). These differences explain why inhaled foreign bodies enter the right principal bronchus more often than the left (these events are more common in children and they may present with breathlessness, unilateral wheeze or recurrent aspirations: a chest radiograph may show air trapping in the affected lobe). The right main bronchus gives rise to its first branch, the superior lobar bronchus, then enters the right lung opposite the fifth thoracic vertebra. The azygos vein arches over it, and the right pulmonary artery lies at first inferior, then anterior, to it. After giving off the superior lobar bronchus, which arises posterosuperior to the right pulmonary artery, the right main bronchus crosses the posterior aspect of the artery, enters the pulmonary hilum posteroinferior to it, and divides into a middle and an inferior lobar bronchus. Normal variants in the bronchial anatomy are occasionally seen and consist of either displaced or supernumerary airways (see Ghaye et al 2001). Abnormalities include a common origin of the right upper and middle lobe bronchi; an accessory cardiac bronchus; and a right lower lobe bronchus that may arise from the left main stem bronchus. These anatomical variants are largely asymptomatic, but occasionally may cause haemoptysis, recurrent infection and development of bronchiectasis of the airway.

LEFT MAIN BRONCHUS

The left principal bronchus, which is narrower and less vertical than the right, is 5 cm long. Passing to the left inferior to the aortic arch, it crosses anterior to the oesophagus, thoracic duct and descending aorta; the left pulmonary artery is at first anterior and then superior to it. It enters the hilum of the left lung at the level of the sixth thoracic vertebra and divides into a superior and an inferior lobar bronchus.

VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

Bronchi

Bronchial arteries

The bronchial arteries supply oxygenated blood to maintain the pulmonary tissues. They are derived from the descending thoracic aorta either directly or indirectly (Baile 1996). The right bronchial artery is usually a branch of the third posterior intercostal artery. There are normally two left bronchial arteries (upper and lower) that branch separately from the thoracic aorta. The bronchial arteries accompany the bronchial tree and supply bronchial glands, the walls of the bronchial tubes and larger pulmonary vessels. The bronchial branches form a capillary plexus in the muscular tunic of the air passages which supports a second, mucosal plexus that communicates with branches of the pulmonary artery and drains into the pulmonary veins. Other arterial branches ramify in interlobular loose connective tissue and most end in either deep or superficial bronchial veins; some also ramify on the surface of the lung, forming subpleural capillary plexuses. Bronchial arteries supply the bronchial wall as far as the respiratory bronchioles, and anastomose with branches of the pulmonary arteries in the walls of the smaller bronchi and in the visceral pleura. These bronchopulmonary anastomoses may be more numerous in the newborn and are subsequently obliterated to a marked degree. In addition to the main bronchial arteries, smaller bronchial branches arise from the descending thoracic aorta: one of these may lie in the pulmonary ligament and may cause bleeding during inferior lobectomy.

MICROSTRUCTURE OF THE CONDUCTING AIRWAYS

The conducting airways are lined internally by a mucosa, and the epithelium lies on a thin connective tissue lamina propria. External to this is a submucosa, also composed of connective tissue, in which are embedded airway smooth muscle, glands, cartilage plates (depending on the level in the respiratory tree), vessels, lymphoid tissue and nerves. Cartilage is present from the trachea to the smallest bronchi, but is absent (by definition) from bronchioles.

Epithelium

The epithelia of the trachea, bronchi and bronchioles are, in general, similar to each other, with graded variations in the numbers of different cell types. The extrapulmonary and larger intrapulmonary passages are lined with respiratory epithelium, which is pseudostratified, predominantly ciliated, and contains interspersed mucus-secreting goblet cells. There are fewer cilia in terminal and respiratory bronchioles, and the cells are reduced in height to low columnar or cuboidal. The epithelium of smaller bronchi and bronchioles is folded into conspicuous longitudinal ridges, which allow for changes in luminal diameter (Fig. 57.9). The epithelium in the respiratory bronchioles progressively reduces in height towards the alveoli, and is eventually composed of cuboidal, non-ciliated cells. Respiratory bronchioles have lateral pouches in their walls, which are lined with squamous cells, so providing an accessory respiratory surface.

Six distinct types of epithelial cell have been described in the conducting airways, namely, ciliated columnar, goblet, Clara, basal, brush and neuroendocrine. Lymphocytes and mast cells migrate into the epithelium from the underlying connective tissue.

Connective tissue and muscle

Broad, longitudinal bands of elastin (Fig. 57.13) within the submucosa follow the course of the respiratory tree and connect with the elastin networks of the interalveolar septa (see Fig. 57.9). This elastic framework is a vital mechanical element of the lung, and is responsible for elastic recoil during expiration.

In the trachea and extrapulmonary bronchi, the smooth muscle is mainly confined to the posterior, non-cartilaginous part of the tracheal tube (Fig. 57.14). Along the entire intrapulmonary bronchial tree, smooth muscle forms two opposed helical tracts which become thinner and finally disappear at the level of the alveoli. The tone of these muscle fibres is under nervous and hormonal control: groups of muscle cells are coupled by gap junctions to spread excitation within fascicles.

Muscle cell contraction narrows the airway, while relaxation permits bronchodilation. Some tone normally exists in the muscular bands, which relax slightly during inspiration and contract during expiration, thereby assisting the tidal flow of air. Abnormal contraction may be caused by circulating smooth muscle stimulants or by local release of excitants such as serotonin, histamine and leukotrienes, which produces bronchospasm. Numerous mast cells are present in the connective tissue of the respiratory tree, especially towards the bronchioles.

Cartilaginous support

The trachea and extrapulmonary bronchi contain a framework of incomplete rings of hyaline cartilage which are united by fibrous tissue and smooth muscle (Fig. 57.14). Intrapulmonary bronchi contain discontinuous plates or islands of hyaline cartilage in their walls.

PULMONARY DEFENSIVE MECHANISMS

The respiratory tract presents a huge surface area that is vulnerable to desiccation, microbial invasion and the mechanical and chemical effects of inhaled particles. Inhaled air is humidified chiefly in the upper respiratory tract where it passes, with some turbulence, over the nasal and buccopharyngeal mucosae. The secretions of the various glands of the bronchial tree also help to prevent desiccation. Goblet cells secrete sulphated acid mucosubstances; cells in mucous glands beneath the epithelial surface contain mainly carboxylated mucosubstances, particularly those associated with sialic acid, although sulphated groups also occur; cells of serous glands contain neutral mucosubstances. Goblet cells respond mainly to local irritation, while tubular glands, both mucous and serous, are mainly under neural and hormonal control. Excessive or altered secretions may obstruct the flow of air. In addition to mucosubstances secreted by bronchial glands, antibacterial and antiviral substances, e.g. lysozyme, antibodies of the IgA type and possibly interferon, also appear in the secreted fluid.

Inhaled particles may be removed via the mucociliary rejection current. Cilia sweep the fluid overlying the surfaces of bronchioles, bronchi and trachea upwards at 1 cm/min, and much of the inhaled matter trapped in the viscous fluid may be removed in this way. Particles small enough to reach the alveoli may be removed by alveolar phagocytes (see p. 998). Alveolar epithelium has limited powers of regeneration but normally is continually replaced. The lifespan of alveolar squamous cells is approximately 3 weeks, and that of alveolar phagocytes is 4 days. Inhaled particles may also be cleared by the cough reflex.

Numerous lymphoid nodules occur in the bronchial lining. They provide foci for the production of lymphocytes and give local immunological protection against infection both by cell-mediated (T-cell) activities, and by the production of immunoglobulins (mainly IgA) from B cells, which are passed on to gland cells for secretion to the epithelial surface.

Anatomy of coughing

Coughing involves an initial deep inspiration, followed by forceful contraction of the expiratory muscles and diaphragm against a closed glottis. This leads to an abrupt rise in pleural pressure (6.5 to 13 kPa) and intra-alveolar pressure. Subsequent glottal opening causes a rapid peak expiratory flow of air, followed by some collapse of the trachea and central airways, which is responsible for the post-peak plateau in flow.

Coughing is initiated when mechanically and chemically sensitive vagal afferents innervating the airways are activated. Data from experimental studies suggest that the receptors innervated by these afferents may be broadly divided into three groups: slowly (SAR) and rapidly (RAR) adapting stretch receptors and bronchopulmonary C fibres. The vagal afferents terminate centrally in largely nonoverlapping regions of the caudal half of the nucleus of the solitary tract; second order neurones from this nucleus terminate in respiratory-related regions of the medulla, pons and spinal cord. Afferent nerves innervating other viscera, and somatosensory nerves innervating the chest wall, diaphragm and anterior abdominal musculature are also likely be involved in regulating cough.

The identity of the afferent terminals in the airways is uncertain; receptors similar to taste buds are considered to be responsible at the laryngeal aditus, and some of the ‘brush cells’ of the respiratory epithelium appear to have neural contacts, and may therefore represent sensory cells with basal synaptic outputs (Widdicombe 2002). Other than the larynx, the carina and branching points of the tracheobronchial tree appear to be the most sensitive areas of the epithelium lining the airways.

For further details, see Kubin et al (2006) and Canning (2006).