LUNGS

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, 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.

PLEURA
Each lung is covered by pleura, a serous membrane.

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.

The right and left pleural sacs form separate compartments and touch only behind the upper half of the
sternal body, although they are also close to each other behind the oesophagus at the midthoracic level. The
region between them is the mediastinum (interpleural space).

LUNGS

The lungs are the essential organs of respiration. They are situated on either side of the heart and other
mediastinal contents. 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.

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.

PULMONARY SURFACE FEATURES

Each lung has an apex, base, three borders and two surfaces.

Apex
The apex, the rounded upper extremity, protrudes above the thoracic inlet, above the medial third of the clavicle.
It is covered by the parietal pleura which forms the pleural dome.

The apex has relations with: the left subclavian artery, brachiocephalic trunk (artery), left and right
brachiocephalic veins, trachea.

Base
The basal surface is semilunar and concave, and rests upon the superior surface of the diaphragm, which
separates:

- the right lung from the right lobe of the liver

- the left lung from the left lobe of the liver, the gastric fundus and spleen.

Since the diaphragm extends higher on the right than on the left, the concavity is deeper on the base of the right
lung.

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Costal surface
The costal surface of the lung is smooth and convex, and its shape is adapted to that of the thoracic wall. It is in
contact with the costal pleura and through this membrane the lung has relations with the ribs and intercostal
muscles.

On this surface it is present the oblique (principal) fissure and horizontal fissure (for the right lung).

Medial surface
The medial surface has a posterior vertebral and anterior mediastinal part.

The vertebral part lies in contact with the sides of the thoracic vertebrae and intervertebral discs. The
mediastinal area is deeply concave, because it is adapted to the heart at the cardiac impression, which is much
larger and deeper on the left lung where the heart projects more to the left of the median plane. Posterosuperior
to this concavity is the hilum, where various structures enter or leave the lung, collectively surrounded by a
sleeve of pleura.

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.

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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.
The diaphragm rises higher on the right to accommodate the liver, and so the right lung is vertically shorter than
the left.

The posterior border separates the costal surface from the mediastinal surface to the posterior, 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. It separates the costal surface from the medial surface
to the anterior. On the left side there is the cardiac impression (or notch, for the apex of the heart).

PULMONARY FISSURES AND LOBES

Right lung
The right lung is divided into superior, middle and inferior lobes by an oblique and a horizontal fissure. The
upper, oblique fissure separates the inferior from the middle and upper lobes, and corresponds closely to the left
oblique fissure. The short horizontal fissure separates the superior and middle lobes.

Left lung
The left lung is divided into a superior and an inferior lobe by an oblique fissure which extends from the costal
to the medial surfaces of the lung both above and below the hilum.

On this lung, at the lower end of the cardiac notch a small process, the lingula, is usually present.

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.

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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. 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 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.

Right hilum
The right root is situated behind the superior vena cava and right atrium and below the terminal part of the
azygos vein. Its structures are: superior lobar bronchus, pulmonary artery, principal bronchus, and lower
pulmonary vein.

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.

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.

Their walls contain two types of epithelial cell (types I and II 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.
They clear the respiratory spaces of inhaled particles which are small enough to reach the alveoli.

Alveolar surfactant
The alveolar surface is normally covered by a film of pulmonary surfactant, which is a complex mixture,
mainly of phospholipids, with some protein and neutral lipid, secreted by type II pneumocytes.

Surface tension at the alveolar surface is very high, because the alveoli are minute. This opposes expansion
during inspiration, and tends to collapse the alveoli in expiration. The detergent-like properties of pulmonary
surfactant greatly reduce the surface tension, and make ventilation of the alveoli much more efficient.

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VASCULAR SUPPLYAND 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 (from the right ventricle) 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. The pulmonary capillaries form plexuses immediately outside the epithelium in the
walls and septa of alveoli and alveolar sacs.

Pulmonary veins, two from each lung, drain the pulmonary capillaries. The pulmonary veins open into the left
atrium and convey oxygenated blood for systemic distribution by the left ventricle.

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, through the pulmonary plexuses.

The anterior and posterior pulmonary plexuses are formed by rami from vagal nerves (parasympathetic
innervation) and branches from the second to fifth thoracic sympathetic ganglia.

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 to the upper border of the fifth thoracic vertebra, where
it divides into right and left principal (pulmonary) bronchi.

TRACHEAL RELATIONS
Cervical part of the trachea
Anterior relations
The cervical trachea is crossed anteriorly by skin, by the superficial and deep cervical fasciae, the thyroid gland.

Posterior relations
The oesophagus lies behind the cervical trachea, separating it from the vertebral column.

Lateral relations
The paired lobes of the thyroid gland, the common carotid, the recurrent laryngeal nerves ascend on each side
(between the sides of the trachea and the oesophagus).

Thoracic part of the trachea

Anterior relations
As it descends through the superior mediastinum, the thoracic trachea lies behind the manubrium sterni, the
thymic remnants; aortic arch, left brachiocephalic veins ; The brachiocephalic artery and left common carotid
artery come to lie on the right and left respectively of the trachea.

Posterior relations
The oesophagus is posterior to the trachea and separates it from the vertebral column.

Lateral relations
Laterally and on the right are the right lung and pleura, right brachiocephalic vein, superior vena cava, right
vagus nerve and azygos vein. On the left are the arch of the aorta, and the left common carotid and left
subclavian arteries, the left recurrent laryngeal nerve.

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Innervation

The trachea is innervated by branches of the vagi, recurrent laryngeal nerves and sympathetic trunks.

MICROSTRUCTURE OF THE CONDUCTINGAIRWAYS

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.

The extrapulmonary and larger intrapulmonary passages are lined with respiratory epithelium, which is
pseudostratified, predominantly ciliated, and contains interspersed mucus-secreting goblet cells.

DIAPHRAGM

The diaphragm is a curved musculofibrous sheet that separates the thoracic from the abdominal cavity. Its
mainly convex upper surface faces the thorax, and its concave inferior surface is directed towards the abdomen.

ATTACHMENTS AND COMPONENTS

The muscle fibres of the diaphragm arise from the circumference of the thoracic outlet.

Although it is a continuous sheet, the muscle can be considered in three parts, sternal, costal and lumbar, which
are based on the regions of peripheral attachment. The sternal part arises from the back of the xiphoid process.
The costal part arises from the internal surfaces of the lower six costal cartilages and their adjoining ribs on each
side. The lumbar part arises from two aponeurotic arches, the medial and lateral arcuate ligaments (sometimes
termed lumbocostal arches) and from the lumbar vertebrae.

From these circumferential attachments, the fibres of the diaphragm converge into a central tendon.

RELATIONS

The central tendon of the diaphragm is a thin but strong aponeurosis. Its shape is trifoliate: anterior leaf, right
and left folia.

The upper surface of the diaphragm is related to three serous membranes. On each side, the pleura separates it
from the base of the corresponding lung, and the pericardium is interposed between the diaphragm and the heart.

Most of the inferior surface is covered by peritoneum. The right side is in relation the convex surface of the right
lobe of the liver, the right kidney and right suprarenal gland. The left side conforms to the left lobe of the liver,
the fundus of the stomach, the spleen, the left kidney and the left suprarenal (adrenal) gland.

APERTURES
A number of structures pass between the thorax and abdomen via apertures in the diaphragm. There are three
large openings, for the aorta, oesophagus and inferior vena cava, and a number of smaller ones.

The aortic aperture is the most posterior of the large openings, and is found at the level of the twelfth thoracic
vertebra, slightly to the left of the midline. The aortic opening transmits the aorta, thoracic duct and other
lymphatic trunks from the lower posterior thoracic wall, the azygos and hemiazygos veins.

The oesophageal aperture is located at the level of the tenth thoracic vertebra, in front of, the aortic
opening. It transmits the oesophagus, gastric nerves, oesophageal branches of the left gastric vessels and some
lymphatic vessels.

The vena cava aperture lies at about the level of the disc between the eighth and ninth thoracic vertebrae. It is
traversed by the inferior vena cava.

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VASCULAR SUPPLY

The lower five intercostal and subcostal arteries supply the costal margins of the diaphragm while the phrenic
arteries supply the main central portion of the diaphragm.

INNERVATION

The diaphragm receives its motor supply via the right and left phrenic nerves, intercostal nerves.