Anatomy, Thorax, Lungs


Article Author:
Raheel Chaudhry


Article Editor:
Bruno Bordoni


Editors In Chief:
Juan Batlle
Jitendra Sisodia
Jeffrey Miller


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
1/13/2019 9:38:19 AM

Introduction

The purpose of the lung is to provide oxygen to the blood. The respiratory system is divided into airways and lung parenchyma. The airways consist of the bronchus which bifurcates off the trachea and divides into bronchioles and then further into alveoli. The parenchyma is responsible for gas exchange and includes the alveoli, alveolar ducts, and bronchioles. Lungs have a spongy texture and have a pinkish gray hue. Also, they are anatomically described as having an apex, three borders, and three surfaces. Further, they are subdivided into lobes and segments. The lung parenchyma also is covered by a pleura.[1][2][3]

Anatomy

Anatomically, the lung is described by an apex, three borders, and three surfaces. The apex lies above the first rib.

The three borders include the anterior, posterior, and inferior borders. The anterior border of the lung corresponds to the pleural reflection, and it creates a cardiac notch in the left lung. The cardiac notch is a concavity in the lung that is formed due to the heart. The inferior border is thin and separates the base of the lung from the costal surface. The posterior border is thick and extends from the C7 to T10 vertebra, which is also from the apex of the lung to the inferior border.

The three surfaces of the lung include the costal, medial, and diaphragmatic surfaces. The costal surface is covered by the costal pleura and is along the sternum and ribs. It also joins the medial surface at the anterior and posterior borders and diaphragmatic surfaces at the inferior border. The medial surface is divided anteriorly and posteriorly. Anteriorly it is related to the sternum, and posteriorly it is related to the vertebra. The diaphragmatic surface (base) is concave and rests on the dome of the diaphragm; the right dome is also higher than the left dome because of the liver.

The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes: right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). The left lung consists of two lobes: right upper lobe (RUL) and right lower lobe (RLL). The right lobe is divided by an oblique and horizontal fissure, where the horizontal fissure divides the upper and middle lobe, and the oblique fissure divides the middle and lower lobes. In the left lobe there is only an oblique fissure that separates the upper and lower lobe.

The lobes further divide into segments which are associated with specific segmental bronchi. Segmental bronchi are the third-order branches off the second-order branches (lobar bronchi) that come off the main bronchus.

The right lung consists of ten segments. There are three segments in the RUL (apical, anterior and posterior), two in the RML (medial and lateral), and five in the RLL (superior, medial, anterior, lateral, and posterior). The oblique fissure separates the RUL from the RML, and the horizontal fissure separates the RLL from the RML and RUL.

There are eight to nine segments on the left depending on the division of the lobe. In general, there are four segments in the left upper lobe (anterior, apicoposterior, inferior and superior lingula) and four or five in the left lower lobe (lateral, anteromedial, superior and posterior).

The hilum (root) is a depressed surface at the center of the medial surface of the lung and lies anteriorly to T5,6 and 7 vertebrae. It is the point at which various structures enter and exit the lung. The hilum is surrounded by pleura which extends inferiorly and forms a pulmonary ligament. The hilum contains mostly bronchi and pulmonary vasculature, along with the phrenic nerve, lymphatics, nodes, and bronchial vessels. Both left and right hilum contain a pulmonary artery, pulmonary veins (superior and inferior), and bronchial arteries. Also, in the left hilum there is one broncus, the principal bronchus, and in the right hilum there are two bronchi, the eparterial and hyparterial bronchi. From anterior to posterior, the order in the hilum is the vein, artery, and bronchus.

Structure and Function

The function of the lung is to get oxygen from the air to the blood, and this is done through the alveoli. The alveoli are a single cell membrane that allows for gas exchange to pulmonary vasculature. There are a couple of muscles that help with inspiration and expiration, such as the diaphragm and intercostal muscles. Sternocleidomastoid and scalene muscles are used for accessory respiration when the patient is in respiratory distress or failure. The muscles help create a negative pressure within the thorax, where the pressure of the lung is less than the atmospheric pressure, to help with inspiration and filling of the lungs. Also, the muscles help with creating a positive pressure within the thorax, where the pressure of the lung is greater than the atmospheric pressure, to help with expiration and emptying of the lung.

Blood Supply and Lymphatics

The main distinction is between the pulmonary artery and bronchial arteries. The pulmonary artery takes deoxygenated blood from the heart to be oxygenated by the lung parenchyma. However, the bronchial arteries provide oxygen for survival to the lung parenchyma.

The main pulmonary artery emerges from the right ventricle and bifurcates into left main and right main pulmonary arteries. The pulmonary artery branches usually trail and expand along the branches of the bronchial tree and eventually become capillaries around the alveoli. The pulmonary veins receive oxygenated blood from the alveoli capillaries and deoxygenated blood from the bronchial arteries and visceral pleura. Four pulmonary veins come together at the right atrium.

Bronchial circulation is part of the systemic circulation. The left bronchial artery arises as two (superior and inferior) from the thoracic aorta. The right brachial artery usually comes from one of the following three: the right posterior intercostal artery, with the left superior bronchial artery off the aorta or directly from the aorta. The bronchial veins collect the deoxygenated blood and empty into the azygos vein.

The superficial and deep lymphatic plexuses drain the lung. The lymph flow from lung parenchyma first drains into the intraparenchymal nodes and then to the peribronchial nodes. Subsequently, the lymphatics will drain to the tracheobronchial, paratracheal lymph nodes, the bronchomediastinal trunk, and then into the thoracic duct.

Nerves

The phrenic nerve comes from C3,4,5 cervical nerve roots. It innervates the fibrous pericardium, portions of the visceral pleura, and the diaphragm.

The lung receives innervation from two main sources: the pulmonary plexus (combination of parasympathetic and sympathetic innervation) and the phrenic nerve. The pulmonary plexus can be found at the root of the lung and consists of efferent and afferent autonomic nerve fibers. It consists of branches of the vagus nerve (parasympathetic) and sympathetic fibers. The plexus branches around the pulmonary vasculature and bronchi. The parasympathetic innervation causes constriction of the bronchi, dilation of the pulmonary vessels, and increase gland secretion. The sympathetic innervation causes dilation of the bronchi and constriction of the pulmonary vessels.

Physiologic Variants

Accessory fissures may occur; these may be superficial or deep at the hilum. They may cause odd patterns on x-ray during specific pathologies.

Other variations that may occur include agenesis (absence of a lung), aplasia, or accessory lobes (can cause imaging variations). 

Surgical Considerations

When the entire lobe of the lung is excised, it is known as lobectomy, and when just the segment is removed, it is known as segmentectomy. A lobectomy may be done when the pathology is only in one lobe and to prevent the spread of a disease, such as in tuberculosis, lung abscess, emphysema, benign tumor, or lung cancer. A segmentectomy is done for benign lesions to preserve the lung, or in bronchiectasis, early stage I cancer, lung nodules, or tuberculosis.[4][5][6]

Saddle pulmonary embolism is an obstruction of the bifurcation of the pulmonary trunk. It is a surgical emergency and requires embolectomy.

Clinical Significance

Percussion of the chest is normally resonant. If there is fluid build up, it can become dull.[7]

On auscultation, if there is wheezing then this is due to bronchoconstriction (asthma). If there are crackles (rales), it is possibly due to pulmonary edema (congestive heart failure, interstitial lung disease, pneumonia). If there are rhonchi, then it is due to secretions in the larger airways causing obstruction (chronic bronchitis, cystic fibrosis).

When reading x-rays, the lungs are black because air is translucent. Pictures come out best when the patient is inhaling.

Thoracocentesis is a procedure that uses a needle to draw out fluid from the lung. It is done to determine the cause of a pleural effusion or abscess. It can be diagnostic or therapeutic (to relieve symptoms such as pain or shortness of breath).[8]

Pneumonia is an inflammation of the lung and can cause pleural effusion. Patients may present with fever, cough, chest pain, nausea, and vomiting.


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Attributed To: Contributed Illustration by Beckie Palmer

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Anatomy, Thorax, Lungs - Questions

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The trachea divides into the left and right mainstem bronchi at which level?



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What is the function of the pores of Kohn?



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Which of the following is a mediastinal lymph node?



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What is the lingula?



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The right middle lobe corresponds to what part of the left lung?



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Where does blood from the bronchial arteries flow?



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The right middle lobar bronchus leads to which of the following segments?



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Which of the following is an eparterial bronchus?



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Which of the following lung lobes is involved in cancer of the cardiac notch?



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The lingula, the tongue-shaped structure is present in which of the following lung lobes?



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The trachea bifurcates into the right and left bronchi at which of the following levels?



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What percent alveoli are present in an infant when compared to an adult?



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The maximal number of alveoli in both lungs is reached by what age?



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The lingula, a tongue-shaped structure, is present in which of the following lung lobes?



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The trachea divides into the left and right mainstem bronchi at what level?



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What lobes make up the right lung?



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Which of the following structures is not associated with terminal bronchioles?



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Which part of the lung has the lingula?



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Which statement is not true of the right upper lobe bronchopulmonary anatomy?

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Regarding lateral chest radiography, which statement is true?



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Which of the following nodal chain drains the diaphragm?



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Which of the following is true about the anatomy of the right upper lobe (RUL) of the lung?

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Which choice lists the correct order from proximal to distal regarding air passage into the lungs?



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Select the incorrect statement about the lungs.



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The lingula is located in which part of the lung?



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Which relationship of lymph nodes in drainage of the lung parenchyma is correct?



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You are assisting a thoracic surgeon who is dissecting the lung to remove a tumor. She is trying to make sure you know your lung anatomy. Which of the following is an incorrect statement from the surgeon?



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A 12-year-old boy is brought into the emergency department by his mother after he accidentally ingested a magnet during playing. His vital signs are all stable. His mother is anxious because she is afraid that he will "become brain damaged". Chest x-ray reveals atelectasis of the right middle lobe. Which of the following part of the conducting system is responsible for atelectasis seen in this patient?



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Which of the following is not relatively large at birth?



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A 27-year old smoker presents to the emergency room with sudden onset of left-sided chest pain. He denies any trauma but claims that while walking his dog he had a sudden onset of chest pain. A chest x-ray is done but it is unremarkable. The patient undergoes a CT scan of the chest and the radiologist states that there is a pneumothorax in the cupola. What part of the chest anatomy is identified by the radiologist?



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Anatomy, Thorax, Lungs - References

References

Tucker WD,Burns B, Anatomy, Thorax, Heart Pulmonary Arteries null. 2018 Jan     [PubMed]
Burlew JT,Banks KP, Anatomy, Thorax, Mediastinal Lymph Nodes null. 2018 Jan     [PubMed]
Donley E,Loyd JW, Anatomy, Thorax, Wall Movements null. 2018 Jan     [PubMed]
Bains KNS,Lappin SL, Anatomy, Thorax, Diaphragm null. 2018 Jan     [PubMed]
Michael CW,Faquin W,Jing X,Kaszuba F,Kazakov J,Moon E,Toloza E,Wu RI,Moreira AL, Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes. Diagnostic cytopathology. 2018 Oct     [PubMed]
Goizueta AA,Bhimji SS, Anatomy, Thorax, Lung Pleura And Mediastinum null. 2018 Jan     [PubMed]
Garvin WH Jr, Clinical examination of the lungs. Comprehensive therapy. 1979 Oct     [PubMed]
Koegelenberg CF,Irusen EM,von Groote-Bidlingmaier F,Bruwer JW,Batubara EM,Diacon AH, The utility of ultrasound-guided thoracentesis and pleural biopsy in undiagnosed pleural exudates. Thorax. 2015 Oct     [PubMed]

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