NEWER CONCEPTS OF ANATOMY OF THE LUNGS—Advantages to Surgeons,Internists, Bronchoscopists and Radiologists

In the newer concept of the anatomical divisions of the lungs, the bronchopulmonary segment is the primary unit. Specific lung areas are identified by their relationship to the branch of the bronchus that serves them. The left upper lobe apical segment, for example, is that which is supplied by the left upper lobe apical bronchus. The boundaries of the segments are definitive; thin tissue surrounds each segment.Some diseases of the lungs tend to progress only “through channels”—reaching a segment via the specific airway serving it, and then frequently remaining within the segmental boundaries.The concept is of particular importance to surgeons because of the trend toward segmental resection and salvage of vital lung tissue. In addition, a more definitive nomenclature, useful to surgeons, internists, radiologists and bronchoscopists in designating the location of a lesion or a foreign body, is possible.     

Branches of the left pulmonary artery vascularizing the left upper pulmonary lobe

The studies were carried out on 100 left lungs taken from dead human bodies of both sexes whose age varied from 16 to 80 years. The pulmonary artery and the bronchus were injected with a 65% solution of duracryl and then digested in sulfuric acid. The specimens obtained were examined to determine the number and dimensions of the branches of the left pulmonary artery penetrating into the upper lobe of the left lung as well as the places at which they branch off from this artery. It was found that in most cases 4 branches ramified from the left pulmonary artery. Their length was 30 mm at the most, and their diameter, 12 mm. In about 50% of the cases the branches which penetrated into the lobe were the apicoanterior trunk, the lingular branch and 1 or 2 subsegmental branches, in about 25% of the cases almost all segmental branches penetrated into the lobe separately. In about 20% of the cases the apicoposterior trunk and independent segmental or subsegmental branches were present. Only in about 5% of the cases did the branches under consideration include the apicoposteroanterior trunk and the remaining segmental and subsegmental branches.     

The bronchial tree,lobular division,and blood vessels of the lung of the silvered lutong (Presbytis cristata)

The lungs of three silvered lutongs (Presbytis cristata) were examined. The right and left lungs have the dorsal, lateral, ventral, and medial bronchiole systems, which arise from the corresponding sides of both bronchi, respectively. Bronchioles in the dorsal and lateral bronchiole systems are well developed, whereas those in the ventral and medial bronchiole systems are poorly developed and lack some portions. According to the fundamental structure of bronchial ramifications of the mammalian lung (Nakakuki, 1975, 1980), the right lung consists of the upper, middle, lower, and accessory lobes, whereas the left lung consists of a bilobed middle lobe and a lower lobe, in which the right upper lobe is extremely well developed. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then across the dorsal side of the right middle lobe bronchiole. Initially it runs along the lateral side of the right bronchus and then gradually comes to run along the dorsal side. During its course, it gives off branches which run mainly along the dorsal or lateral side of the bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole, and then follows the same course as that in the right lower lobe. The pulmonary veins run medially or ventrally to the bronchioles, and finally enter the left atrium as four or five large veins.     

LOBAR PNEUMONIA—The Distribution of Sites in Infants and Children

In a review of roentgenograms of 228 pediatric patients with segmental pneumonia, the left upper lobe was observed to be involved in only 4 per cent of cases. The right upper lobe was involved most frequently—over eight times as often as the left upper lobe and twice as often as the right middle or lower lobe. It is suggested that this distribution is related to the fact that the angle of the left bronchus in relation to the median plane is more acute than the angle of the right bronchus, the sharper angle perhaps serving as protection against aspiration.     

Distribution of the pulmonary artery and vein in the lung of the white handed gibbon

The lungs of four white handed gibbons (Hylobates agilis) were examined. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then traverses the dorsal side of the right middle lobe bronchiole. Thereafter, it runs along the dorso-lateral side of the right bronchus, between the dorsal bronchiole system and the lateral bronchiole system, and gradually follows the dorsal side of the right bronchus. During its course, it gives off arterial branches which run along each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole and then along the left bronchus as in the right lung. The branches of the pulmonary artery run mainly along the dorsal or lateral side of the bronchiole, while the pulmonary veins run mainly the medial side of the bronchioles or between them. However, in a few portions, the pulmonary veins run the lateral side of the bronchioles. Finally, they enter the left atrium with four large veins i.e. the common trunk of the right upper lobe vein and right middle lobe vein, right lower lobe pulmonary venous trunk, left middle lobe vein, and left lower lobe pulmonary venous trunk.     

Reversibility of complete unperfusion in a patient with recurrent hemoptysis

We present a case of a 68-year-old woman with a history of mild smoking and chronic bronchitis who showed recurrent hemoptysis. She presented with a nearly normal chest roentgenogram, a non-diagnostic fiberoptic bronchoscopy and a computed tomography and lung scanning both of which were highly suggestive for malignancy. In fact, the former showed obstruction of the main left bronchus, of the superior bronchus for the left upper lobe and of the apical bronchus for the left lower lobe, the latter showed a total cessation of blood flow through the left lung. Pulmonary angiography, however, was normal and aortography showed dilatated and twisted left bronchial arteries. Computed tomography and lung scanning came back to normal after bronchoscopic aspiration of endobronchial clots and a nonspecific antibiotic therapy were carried out. Although very infrequent, bronchial stenosis on CT and complete monolateral unperfusion on lung scintigraphy may occur in patients with hemoptysis of benign origin. We recommend the use of pulmonary arteriography in patients with the above pattern when diagnostic doubt remains after bronchoscopy.     

The lobular division,bronchial tree and blood vessels of the squirrel monkey lung

The lobular division, bronchial tree, and blood vessels in lungs of seven squirrel monkeys (Saimiri sciureus) were examined from the viewpoint of comparative anatomy. The right lung of the squirrel monkey consists of the upper, middle, lower, and accessory lobes, whereas the left lung consists of the upper, middle, and lower lobes. These lobes are completely separated by interlobular fissures. In three of seven examples examined the left middle lobe was lacking. The squirrel monkey lung has four bronchiole systems, i.e. dorsal, lateral, ventral, and medial, on both sides. The upper lobes are formed by the first branches of the dorsal bronchiole systems. The middle lobes are formed by the first branches of the lateral bronchiole systems. The remaining bronchioles constitute the lower lobes. In addition to the above lobes, in the right lung, the accessory lobe is present, being formed by the first branch of the ventral bronchiole system. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then across the dorsal side of the right middle lobe bronchiole. Thereafter, it runs between the dorsal bronchiole and lateral bronchiole systems along the dorso-lateral side of the right bronchus. During its course, the right pulmonary artery gives off the arterial branches which run along each bronchiole. These branches run mainly along the dorsal or lateral side of the bronchioles. In the left lung, the pulmonary artery and its branches run the same course as in the right lung. The pulmonary veins run mainly the ventral or medial side of the bronchioles, and between the bronchioles.     

The ventilatory patterns of the left upper lobe of lung

Having knowledge on models of the bronchial tree branching, is of a special interest for clinical and surgical pulmology, because the hemilobectomy, segmentectomy and subsegmentectomy are always determined by intralobar, intrasegmental and intrasubsegmental bronchial ramification. Investigations were performed on 100 lungs of children and adults of both sexes, one day to 85 years old, randomly chosen. There are two main types of branching of the left upper lobe bronchus: the bifurcation pattern as dominant model in 74% and the trifurcation model found in 26%. Out of 100 lungs studied, 21 lungs had the ventilatory variations of the bronchopulmonary segments. The classification and categorization of the ventilatory of bronchopulmonary segments of the left upper lobe of lung were made. This classification contains 5 categories and 8 subcategories.     

The bronchial tree and blood vessels of the Japanese monkey lung

The author injected various colored celluloid solutions into the bronchial tree and blood vessels of the lungs of five adult Japanese monkeys (Macaca fuscata) in order to prepare cast specimens. These specimens were investigated from the comparative anatomical viewpoint to determine whether the bronchial ramification theory of the mammalian lung (Nakakuki, 1975, 1980) can be applied to the Japanese monkey lung or not. The bronchioles are arranged stereotaxically like those of other mammalian lungs. The four bronchiole systems, dorsal, ventral, medial, and lateral, arise from both bronchi, respectively, although some bronchioles are lacking. In the right lung, the bronchioles form the upper, middle, accessory, and lower lobes, while in the left lung, the upper and accessory lobes are lacking and bi-lobed middle and lower lobes are formed. In the right lung, the upper lobe is formed by the first branch of the dorsal bronchiole system. The middle lobe is the first branch of the lateral bronchiole system. The accessory lobe is the first branch of the ventral bronchiole system. The lower lobe is formed by the remaining bronchioles of the four bronchiole systems. In the left lung, the middle lobe is formed by the first branch of the lateral bronchiole system. The lower lobe is formed by the remaining bronchioles. Thus, the bronchial ramification theory of the mammalian lung applied well to the Japanese monkey lung. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole. It then runs along the dorso-lateral side of the right bronchus between the dorsal bronchiole system and the lateral bronchiole system. On its way, it gives off branches of the pulmonary artery which run along the dorsal or lateral side of each bronchiole except in the ventral bronchiole system. In the ventral bronchiole system, the branches run along the ventral side of the bronchioles. The distributions of the pulmonary artery in the left lung are the same as those in the right lung. The pulmonary veins do not always run along the bronchioles. Most of them run on the medial or ventral side of the bronchioles. Some of them run between the pulmonary segments. In the right lung, these pulmonary veins finally form the right upper lobe vein, right middle lobe vein and the right lower lobe pulmonary venous trunk before entering the left atrium. However, the right accessory lobe vein runs on the dorsal side of the bronchiole and pours into the right lower lobe pulmonary venous trunk. In four cases out of the five examples, part of the right lower lobe veins pour into the right middle lobe vein, while the others enter the right lower lobe pulmonary venous trunk. In the left lung, the branches of the pulmonary veins finally form the left middle lobe vein and the left lower lobe pulmonary venous trunk.     

Distribution of the pulmonary artery and vein of the orangutan lung

The distribution of the pulmonary artery and vein of the orangutan lung was examined. The right pulmonary artery runs obliquely across the ventral side of the right bronchus at the caudally to the right upper lobe bronchiole. It then runs across the dorsal side of the right middle lobe bronchiole. Thereafter it runs obliquely across the dorsal side of the right bronchus, and then along the dorso-medial side of the right bronchus. This course is different from that in other mammals. During its course, it gives off branches which run mainly along the dorsal or lateral side of each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole, then along the dorso-lateral side of the left bronchus, giving off branches which run along each bronchiole. The pulmonary veins run mainly the ventral or medial side of, along or between the bronchioles. In the left lung, the left middle lobe vein has two trunks; one enters the left atrium, and the other enters the left lower lobe pulmonary venous trunk. This is also different from that found in most mammals. Finally, the pulmonary veins enter the left atrium with four large veins.     

The bronchial tree and lobular division of the chimpanzee lung

The bronchial ramification and lobular division in lungs of two chimpanzees (Pan troglodytes) were examined from the viewpoint of comparative anatomy, on the basis of the fundamental structure of bronchial ramification of the mammalian lung (Nakakuki, 1975, 1980). The right lung of the chimpanzee consists of the upper, middle, and lower lobes, whereas the left lung consists of the middle and lower lobes. The right and left lungs have the dorsal bronchiole system, lateral bronchiole system, and medial bronchiole system. The ventral bronchiole system is lacking on both sides. The right upper lobe is formed by the first branch of the dorsal bronchiole system. The right middle lobe is formed by the first branch of the lateral bronchiole system, and the right accessory lobe bronchiole is lacking. The remaining bronchioles constitute the right lower lobe. In the left lung, the upper and accessory lobes are lacking. The well developed middle lobe is formed by the first branch of the lateral bronchiole system. The left lower lobe is formed by the remaining bronchioles. Furthermore, these bronchioles are compared with those of the human lung byBoyden (1955).     

Expiratory flow limitation in dogs with regional changes in lung mechanical properties

We examined maximum expiratory flow (Vmax) in two canine preparations in which regional changes in lung mechanical properties were produced. In one experiment serial bronchial obstructions were made to determine whether flow-limiting sites (choke points, CP) would occur in series. With the right lung tied off, constrictions were placed at the left lower lobar bronchus (LLL) and left main-stem bronchus. On deflation from total lung capacity, the obstructed LLL and nonobstructed left upper lobe (LUL) emptied into the obstructed left main-stem bronchus. Although a CP common to both lobes was identified at the main-stem obstruction, which limited total Vmax, we questioned whether there was also a CP at the lobar obstruction that fixed LLL flow. In that case the rate of LLL emptying would not be dependent on the presence of the common (i.e., central) CP and thus the flow contribution of the LUL. We found that when the LUL was removed, the LLL increased its rate of emptying. Thus a lobar CP did not fix LLL flow and CP did not occur in series. In a second experiment emphysema was produced in the left lung to reduce lung recoil, whereas the right lung was normal. CP were identified at approximately lobar bronchi of each lung, and the lungs were emptied at different rates. A CP common to both lungs was not identified. Our results indicate that in localized lung disease, if flows from the different regions are high enough, then wave speed is reached in proximal airways, and a CP occurs centrally rather than peripherally. On the other hand, if flows are low, then wave speed is reached peripherally and a CP common to all lung regions does not occur.     

Pressure-volume curve of lung and lobes in kittens

In the neonatal period, the incomplete aeration of the lung parenchyma and the presence of some pulmonary fluid could determine inequalities in the mechanical behavior of lung regions, favoring unevenness of ventilation distribution. We studied the pressure-volume (PV) curve of excised lungs of kittens in the 1st wk of life 1) by changing the volume a known amount and measuring the corresponding changes in transpulmonary pressure (PL) and 2) by ventilating them at a fixed PL at a rate of 20 cycles/min. An expiratory load equal to the value of PL at the resting volume of the respiratory system was added to avoid the collapse of the lung. A lobar bronchus was then tied, and the measurements were repeated. The difference in PV curves before and after ligature therefore represented the PV curve of the lobe. This was done for all the lobes (upper and middle right, lower right, lower left, upper left) in a random order. A total of 20 lungs and 61 lobes have been studied. Individual lobes were not different in terms of dry-to-wet weight ratio, compliance per unit weight, or per maximal volume and shape of the PV curve, indicating a similar mechanical behavior. Dynamic lung compliance averaged 76% +/- 15 SD of the static value, suggesting some degree of asynchronous behavior of lung regions or viscoelastic properties of the tissue.     

The bronchial tree,lobular division,and blood vessels of the lung of the Diana monkey (Cercopithecus diana)

The authors examined the lung of one Diana monkey (Cercopithecus diana). The right lung consists of upper, middle, lower, and accessory lobes, the upper and middle lobes being united dorsally. The accessory and lower lobes are separated from the other lobes by fissures. The left lung consists of a bi-lobed middle lobe and a lower lobe. These lobes are separated by an interlobular fissure. The Diana monkey has dorsal, lateral, ventral, and medial bronchiole systems on either side. The upper lobe is formed by the first bronchiole of the dorsal bronchiole system. The middle lobe is formed by the first bronchiole of the lateral bronchiole system and the accessory lobe is formed by the first bronchiole of the ventral bronchiole system. The remaining bronchioles of the four bronchiole systems constitute the lower lobe. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then across the dorsal side of the right middle lobe bronchiole. Thereafter, it runs between the dorsal and lateral bronchiole systems, along the dorso-lateral side of the right bronchus. During its course, the right pulmonary artery gives off arterial branches running along the dorsal or lateral side of each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole. Thereafter, it follows the same course as in the right lung, giving off arterial branches. The pulmonary veins run along the ventral or medial side of the bronchiole, and between the bronchioles.     

The bronchial tree and lobular division of the lung of the white handed gibbon

The bronchial tree and lobular division of the lungs of four white handed gibbons (Hylobates agilis) were examined from the viewpoint of comparative anatomy, based upon the fundamental structure of the bronchial ramifications of the mammalian lung (Nakakuki, 1975, 1980). The right lung of the white handed gibbon consists of the upper, middle, lower, and accessory lobes, whereas the left lung consists of the middle and lower lobes. Each lobe is separated by the interlobular fissure, on both sides. The right and left lungs have the dorsal bronchiole system, lateral bronchiole system, and ventral bronchiole system. The medial bronchiole system is lacking on both sides. In the right lung, the upper lobe is formed by the first branch of the dorsal bronchiole system. The middle lobe is formed by the first brach of the lateral bronchiole system, and the accessory lobe by the first branch of the ventral bronchiole system. The remaining bronchioles constitute the right lower lobe. In the left lung, the upper lobe bronchiole, which is the first branch of the dorsal bronchiole system, is lacking. Therefore, the middle lobe bronchiole, i.e. the first branch of the lateral bronchiole system, is well developed. The accessory lobe bronchiole, the first branch of the ventral bronchiole system, is also lacking. The remaining bronchioles constitute the left lower lobe. These features were compared with those of other apes and man.     

Virtual bronchoscopy and 3D spiral CT reconstructions in the management of patient with bronchial cancer--our experience with Syngo 3D postprocessing software

Multislice helical CT generated virtual bronchoscopy (VB) represents one of the most recent developments in three-dimensional computer aided visualisation techniques. VB allows non-invasive and relatively accurate 3D evaluation of tracheobronchal tree. We performed virtual bronchoscopy and in-space 3D volume analysis on CT-data set acquired from sixty-four-year old male with bronchial cancer in order to demonstrate advantages and disadvantages of these methods in diagnostics and preoperative management of metastatic bronchial cancer. Siemens Somatom Emotion 16 helical CT scanner was used for data acquisition. Data post-processing was done with 3D Syngo 2006G software package from Siemens medical systems. CT scanning of the thorax was performed in heavy smoker with an expansive T4N1M1 malignant process in a superior lobe of the right lung accompanied with large metastatic lesion attached on the right lateral chest wall. Metastatic lesions were also found in vertebral column. In-space 3D analysis followed with virtual bronchoscopy had revealed obstruction of apical branch of superior lobe segmental bronchus. External compression done by tumor to the superior segmental and right main bronchus was found. We concluded that multi-slice CT in connection with VB became a possible non-invasive alternative to bronchoscopy, if tissue samples are not required.     

Distribution of the pulmonary artery and vein in the lung of the crab-eating monkey (Macaca fascicularis)

In the lung of the crab-eating monkey (Macaca fascicularis), the right pulmonary artery runs across the ventral side of the right upper lobe bronchiole and the dorsal side of the right middle lobe bronchiole. Thereafter, it courses along the dorso-lateral side of the right bronchus, between the dorsal and lateral bronchiole systems. During this course, the right pulmonary artery gives off arterial branches running mainly along the dorsal or lateral side of each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole, and is then distributed as in the right lower lobe. The pulmonary veins run mainly along the ventral or medial side of the bronchiole in the upper and middle lobes whereas, in the lower lobe, they run ventrally, and between the bronchioles. Finally they enter the left atrium as four large veins.     

Double primary lung cancers: with special reference to their exfoliative cytology and to the rare, malignant "mixed" tumor of the salivary-gland type

Two autopsy cases are reported in which double primary cancers of the lung had been strongly or definitely suspected before death by demonstration of two different types of malignant cells in the sputum as well as in smears of aspirates from pleural fluid and/or mediastinal tumor. By exfoliative cytology, one case was characterized by carcinoma cells of the small-cell type plus the large-cell and/or adenocarcinoma type; the other displayed small-cell-type and squamous-cell-type malignant cells. The autopsies definitely revealed in the first case an anaplastic carcinoma of the small-cell type in the left bronchus and a salivary-gland-type malignant "mixed" tumor in the right lower lobe and in the second case an anaplastic carcinoma of the small-cell type in the right upper lobe and a squamous-cell carcinoma in the left upper lobe. The frequence of occurrence and pathologic diagnosis of double primary lung cancers are reviewed and discussed. A rare type of lung cancer, salivary-gland-type malignant "mixed" tumor, is given special reference.     

Cigarette smoke acutely increases collateral resistance in excised dog lobes

The acute effects of cigarette smoke or drug inhalation on collateral conductance (Gcoll) were studied in freshly excised dog lobes held at fixed volumes. A double-lumen catheter was wedged into a segmental bronchus, and air, smoke, or aerosol flowed into the blocked segment at a constant pressure of 2 cmH2O. A capsule glued over a small area of perforated pleura of the segment was used to measure alveolar pressure; the capsule could also be used to measure small airway flow (Vcap) through the segment. Gcoll was almost linearly dependent on lung volume, rising about fivefold between 20 and 100% inflation (30 cmH2O). During smoke inhalation Gcoll began decreasing almost immediately, roughly halving with the first cigarette and falling to about 20% after two cigarettes. Similar proportions were obtained at other lung volumes. Pulmonary conductance (oscillator) in the remainder of the lobe decreased only modestly to 78% of control after two cigarettes. In lobes exposed to 4.5% CO2 after air Gcoll rose 25-50%, but Vcap increased only 5-10%. However, acetylcholine chloride aerosol reduced both flows by similar ratios. Isoproterenol did not prevent or reverse smoke-induced collateral constriction but did reverse the effects of acetylcholine on both pathways. These results suggest that in excised lungs aerosols acted on larger segmental airways in series with collateral channels and with peripheral airways, whereas CO2 and particularly cigarette smoke provoked more marked effects on the most distal smooth muscle.     

实验猕猴肺部CT影像断层初步观察

目的应用CT技术对成年实验猕猴胸部肺窗进行断层扫描观察,探讨CT技术对猕猴肺部疾病的临床诊断意义,建立正常猴肺部CT断层扫描图谱,为CT技术在猕猴解剖学的研究、疾病的临床诊断及科学实验方面的应用,提供影像学的基础资料。方法经过触诊、叩诊、听诊、体温、呼吸率、心率、呼吸运动、血液常规等检查,选择健康猴10只,雌雄各半,年龄分别为5～10岁,进行肺部CT断层扫描检测。试验猴全身麻醉后,置于CT诊断床上,取头前尾后仰卧位进行肺部扫描,获取肺窗扫描图像。对具有解剖意义的扫描图像的每个层面的主要结构（肺叶、气管、动脉血管、静脉血管等）进行标注。结果 （1）获得具有解剖意义的肺窗扫描图像13张。（2）在断层扫描的图像中,肺、气管、较大血管等组织器官界面清晰。肺为左右两侧,左肺分为上叶、中叶、下叶,右肺分为上叶、中叶、下叶、奇叶四部分。不同的断层面分别可见肺部左主支气管、右主支气管、支气管、血管等组织。（3）肺部较小或细小的血管、神经组织界面不清晰。结论 （1）应用CT获得的正常猕猴胸部肺窗断层扫描图像表明,正常健康猴双肺纹理清晰,走行自然,肺野透光度良好,双肺无异常实质病变影像。（2）获得了健康猕猴肺部的CT影像学资料,为猕猴肺部疾病的诊断,提供了一种安全、方便又准确的新依据,建立了成年健康猕猴肺部CT断层解剖研究的背景资料。