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Lung Anatomy: Overview, Gross Anatomy, Microscopic Anatomy

Lung Anatomy
Author: Eduardo A Celis, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Updated: Feb 20, 2013

Overview
The anatomy of the respiratory system can be divided into 2 major parts, airway
anatomy and lung anatomy.
Airway anatomy can be further subdivided into the following 2 segments:
The extrathoracic (superior) airway, which includes the supraglottic, glottic,
and infraglottic regions
The intrathoracic (inferior) airway, which includes the trachea, the mainstem
bronchi, and multiple bronchial generations (which have as their main
function the conduction of air to the alveolar surface)
Lung anatomy includes the lung parenchyma, which carries part of the conduction
system but is mainly involved in the gas exchange at the alveolar level. The lung
parenchyma is further subdivided into lobes and segments.
The purpose of this chapter is to provide a better understanding of the anatomy of
the airways and lungs, which will help the health provider to recognize and manage
different respiratory abnormalities.

Gross Anatomy
Trachea
The trachea is a cartilaginous and fibromuscular tube that extends from the inferior
aspect of the cricoid cartilage (sixth cervical vertebra level) to the main carina (fifth
thoracic vertebra level). Its length is 3 cm at birth and 10-12 cm in adults (of which
2-4 cm is extrathoracic and 6-9 cm intrathoracic). Tracheal diameters vary widely,
ranging from 13 to 25 mm (coronal plane) in men. In women, the variability is still
noted, with a range of 10-21 mm (coronal plane). The shape of the intrathoracic
trachea changes during expiration as a result of invagination of the posterior wall,
causing as much as a 30% reduction of the anteroposterior diameter as seen on
dynamic computed tomography (CT) scanning (see the images below). [1]

Dynamic CT scan of chest during inspiration in normal patient.

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Dynamic CT scan of chest during expiration in normal patient. See how anteroposterior diameter of
the trachea decreases because of collapse of posterior w all.

The tracheal wall has 4 different layers: mucosa, submucosa, cartilage or muscle,
and adventitia. The posterior tracheal wall lacks cartilage and instead is supported
by a thin band of smooth muscle.

Bronchi
The airways divide by dichotomous branching, with approximately 23 generations
of branches from the trachea to the alveoli (see the images below).

Bronchial tree w ith nomenclature.

CT scan of chest (coronal view ). Trachea, main carina, and right mainstem bronchus w ith upper,
middle, and low er lobe airw ays can be seen. Left mainstem bronchus is also seen w ith upper lobe
airw ay. Left low er lobe airw ay cannot be seen.

Bronchi are composed of cartilaginous and fibromuscular elements; however, the

distinction between these elements is less clear-cut in the bronchi than in the
trachea, especially on the more distal airways. The wall thickness is
approximately proportional to the airway diameter on airways distal to the

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segmental branches. For airways less than 5 mm in diameter, the wall should
measure 1/6 to 1/10 of the diameter.
Different systems of nomenclature have been applied to the bronchial tree over the
years. [2] In general usage, there are 2 mainstem bronchi (right and left) and 3 lobar
bronchi (right), with a total of 10 segmental bronchi; 2 lobar bronchi are found on
the left, with a total of 8 segmental bronchi. No accepted terminology for
subsegmental bronchi exists. The terminal bronchioles, including respiratory
bronchioles, alveolar ducts, and alveolar sacs, are discussed elsewhere (see
Microscopic Anatomy section). Generally, the length and diameter of the central
airways vary from right to left.
The vascular supply of the trachea and bronchial tree depends on branches from
the inferior thyroid arteries, intercostal arteries, and bronchial arteries (aortic
branches). These arteries (except the thyroid artery) form a peribronchial plexus
that follows the bronchial tree deep into the lung parenchyma to supply blood also
to the visceral pleura and the walls of the pulmonary arteries and veins (vasa
vasorum).

Lungs
Some symmetry exists between the right and the left lungs. Both lungs are divided
into lobes (see the image below). The gross functional subunits of each lung are
called segments and have a close relation with the segmental bronchi described
above. The right lung comprises 10 segments: 3 in the right upper lobe (apical,
anterior and medial), 2 in the right middle lobe (medial and lateral), and 5 in the
right lower lobe (superior, medial, anterior, lateral, and posterior). The left lung
comprises 8 segments: 4 in the left upper lobe (apicoposterior, anterior, superior
lingula, and inferior lingula) and 4 in the left lower lobe (superior, anteromedial,
lateral, and posterior).

Lung anatomy: lobes and segments.

The lungs are covered by the visceral pleura, which is contiguous with the parietal
pleura as it reflects from the lateral surfaces of the mediastinum. The visceral
pleura forms invaginations into both lungs, which are called fissures. There are 2
complete fissures in the right lung and 1 complete fissure with an incomplete
fissure in the left (see the image below); these separate the different lung lobes.
The pleura also forms the pulmonary ligament, which is a double layer of pleura
that extends caudad along the mediastinum from the inferior pulmonary vein to the
diaphragm.

CT scan of chest (coronal view ). Blue arrow points at minor fissure in right lung. Red arrow s
show both major fissures.

Pulmonary vasculature
A close relation exists between the bronchial tree and the anatomy of the

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pulmonary vasculature, composed mainly of the pulmonary arteries and veins (see
the image below). The main pulmonary artery originates in the right ventricle and
divides into 2 branches. The right pulmonary artery passes posterior to the aorta
and the superior vena cava, emerging lateral to the atria and anterior and slightly
inferior to the right mainstem bronchus. In contrast, the origin of the left pulmonary
artery is situated anterior to the left mainstem bronchus. The arborization of the
pulmonary arteries varies from right to left but mainly divides into truncal, lobar,
segmental, and subsegmental arteries, which generally follow the branches of the
bronchial tree.

Pulmonary artery and vein in relation to airw ays and lungs.

The pulmonary veins originate in the alveoli and also receive drainage from the
bronchial and pleural branches. After the confluence of the small branches into
bigger ones, 2 pulmonary veins, superior and inferior, are formed on each side.
These 4 veins typically join at or near their junction with the left atrium, and usually
this common area is intrapericardial.

Pulmonary lymphatic system

The lymphatic drainage of the lungs start with lymphatic vessels that first drain into
intraparenchymal lymphatics and lymph nodes, then move to peribronchial (hilar)
lymph nodes, and subsequently move to subcarinal, tracheobronchial, and
paratracheal lymph nodes (see the images below). The lymphatics eventually
communicate with the venous system via the bronchomediastinal lymphatic trunk
and the thoracic duct or via the inferior deep cervical (scalene) lymph nodes.
However, some variants of the lymphatic drainage are very important to consider
overall in the dissemination of pulmonary neoplasms (see Pathophysiologic
Variants).

Mediastinal and hilar lymph nodes. Terms reflect nomenclature used for staging of lung cancer.

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CT scan of chest (coronal view ) show ing different mediastinal and hilar lymph nodes. (Red arrow :
station 4 left; green arrow : station 7; yellow arrow : station 11 right.) Terms based on lung cancer
nomenclature.

Microscopic Anatomy
The trachea has multiple layers (see the image below). The mucosa is composed
of a ciliated pseudostratified columnar epithelium and numerous mucus-secreting
goblet cells that rest on a basement membrane with a thin lamina propria (mainly
collagenous). The submucosa contains seromucous glands. The adventitia
contains cartilaginous rings interconnected by connective tissue. The hyaline
cartilage rings have the form of the letter C and are opened posteriorly. The open
ends are connected by fibroelastic tissue and a band of smooth muscle (the
trachealis).

Microscopic picture of trachea show ing different layers: mucosa, submucosa, cartilage.

The epithelium of the bronchus is pseudostratified columnar ciliated epithelium,

also with numerous goblet cells. This epithelium transitions first into a simple
columnar ciliated epithelium and then into a cuboidal epithelium as it continues
branching into smaller bronchioles. The cartilage support is eventually lost at the
bronchiolar level (0.5-1.0 mm diameter). The muscle layer becomes the dominant
structure and is composed of smooth muscle and elastic fibers (see the image
below). At this level, the mucosa may be highly folded because of the loss of
supporting structure.

Microscopic picture of bronchus (hematoxylin and eosin stain). Note mucosal layer w ith multiple
goblet cells. Smooth muscle layer is in periphery. Image courtesy of Dr. Chad Stone.

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The terminal bronchioles are considered the respiratory zone of the lungs (ie, the
area where gas exchange occurs). They divide into respiratory bronchioles, which
continue downstream as alveolar ducts that are completely lined with alveoli and
alveolar sacs (see the image below). Over 300 million alveoli exist in the human
lung, all of them covered by an extensive network of capillaries (branches from the
pulmonary arteries). The respiratory zone constitutes most of the lung (2.5-3 L).

Microscopic picture (hematoxylin and eosin stain) of alveolar sacs and alveoli. Image courtesy of
Dr. Chad Stone.

The epithelium of the respiratory bronchiole is primary cuboidal and may be

ciliated; goblet cells are absent. The supporting thin layer is formed by collagenous
and smooth muscle. Alveoli appear as small pockets that interrupt the main wall.
The terminal portion of the respiratory duct gives rise to the alveolar sacs
(composed of a variable number of alveoli). The alveoli are the smallest and most
numerous subdivisions of the respiratory system. The interalveolar septum often
contains 10-15 m openings between neighboring alveoli that help equalize air
pressures among them.
The alveolar wall is very thin (25 nm) and formed by squamous epithelium (type I
cells) covered by a thin film of surfactant fluid rich in hydrophilic phospholipid
produced by type II cells (septal cells). This surfactant fluid keeps the alveoli open
by reducing the surface tension of the interface between opposing alveolar
surfaces, which reflects into reduced inspiratory work.
The respiratory epithelium is composed mainly of type I cells (98%), along with
some type II cells. The basal lamina is in intimate contact with the capillaries from
the pulmonary vascular system, favoring the transfer of oxygen to the red blood
cells and the release and transfer of carbon dioxide to the alveolar airway.

Natural Variants
As a human being develops from a fetus to a fully developed adult, several changes
take place. Some of these changes follow regular patterns, and others either
compensate for certain conditions or occur for unknown reasons.
Congenital anatomic variants of the lungs are present in the following forms:
Agenesis - A congenital complete absence of one or both lungs, the latter
being incompatible with life; the condition is associated with other
congenital abnormalities and is rare
Aplasia or hypoplasia - The presence of a rudimentary bronchus that ends
in a blind pouch with no evidence of pulmonary vasculature or lung
parenchyma
Accessory lobes, and fusion of lobes - Variations over the lung lobes that
are mainly caused by the incomplete obliteration of the visceral pleural
folds, result from the presence of abnormal vessels (creating extra lobes), or
occur secondary to (completely or partially) fused lobes from obliteration of
the normal lung fissures (see the images below) [3]

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CT scan of chest in patient w ith congenital third fissure in right lung. Abnormal fissure is
seen below major fissure in right.

Azygous lobe. This lobe w as created by azygous vein as it descended into thorax during
embryonic development.

Congenital anatomic variants of the airway are present in the following forms:
Bronchial variations - Variations in the patterns of the bronchial tree are
predominantly due to displacement of segmental and subsegmental bronchi
(reduction migration and selection theories) [4] ; anatomic abnormalities of
the bronchi may be the favored locales for deformities, chronic
inflammations (see the image below), and bronchial neoplasms

CT scan of chest in patient w ith acquired right middle lobe bronchiectasis due to chronic
nontuberculosis mycobacterial infection.

Congenital anatomic variants of the diaphragm are present in the following forms:
Normal variations in the diaphragm are mainly consistent with different sites
of insertion of the muscle that form the diaphragm, or due to congenital
defect leading to communication from the abdominal to the chest cavity (eg,
Bochdalek hernia, Morgani hernia, diaphragmatic eventration) (see the
image below)

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Congenital diaphragmatic hernia, w ith displacement of liver and intestines into chest cavity.

Pathophysiologic Variants
Pathologic variants are related to changes in the structure of the airways, the lung
parenchyma, or adjacent structures that lead to disruption of the normal anatomy
of the respiratory system. The most common such variants are as follows.

Emphysema/chronic obstructive pulmonary disease

Emphysema and chronic obstructive pulmonary disease are caused by an
accumulation of inflammatory mucus that gives rise to a loss of elastic recoil
resulting from lung tissue destruction or to an increase in the resistance of the
conducting airways leading to an abnormal permanent enlargement of air spaces
distal to the terminal bronchioles (see the images below).

CT scan of chest in patient w ith emphysema from smoking. Note formation of bullae in upper lobes.

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Microscopic picture of emphysematous lung (hematoxylin and eosin stain). Upper part of picture
show s destruction of alveolar septa. Low er part of picture show s normal alveoli. Image courtesy
of Dr. Chad Stone.

Pneumothorax, hemothorax, and hydrothorax

Pneumothorax, hemothorax, and hydrothorax are caused by a decrease in lung
volume secondary to the presence of air, blood, or fluid between the visceral and
parietal components of the pleura (see the images below).

Chest radiography of patient w ith spontaneous right pneumothorax. Red arrow s delineate lung
edge.

CT scan of chest in same patient w ith spontaneous right pneumothorax.

Chest radiography of patient w ith right pleural effusion.

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CT scan of chest in same patient w ith right pleural effusion. Red arrow s point at effusion. Left lung
is normal.

Diaphragmatic hernias
Diaphragmatic hernia occurs when a defect in the diaphragm allows the abdominal
contents to move into the chest cavity (see the image below). This could be
congenital, traumatic, iatrogenic, or due to a weakness over the muscles forming
the diaphragm.

CT scan of chest of patient w ith large left diaphragmatic hernia. Note bow el loops and mesenterium
inside left chest cavity.

Bronchial and tracheal stenosis

Bronchial and tracheal stenosis occurs as a result of secondary and numerous
malignant and benign processes and is also a consequence of surgical procedures
and trauma (see the images and video below). The main defect is the obstruction
or collapse of the airways at any level, which leads to changes in air flow that
result in hypoxemia.

Chest radiography of female patient w ith tracheal stenosis due to previous endotracheal intubation.
Red arrow s show area of narrow ing in trachea.

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Bronchoscopic picture of trachea show ing area of stenosis (cicatricial stenosis) from previous
endotracheal intubation.

CT scan of chest in patient w ith tracheal stenosis due to lung cancer. Yellow arrow s show tumor
invading lateral w all and grow ing into trachea, causing stenosis. (T=tumor).

CT scan of chest of patient w ith endobronchial carcinoid tumor of right mainstem bronchus (red
arrow s) causing complete collapse of right lung.
This video demonstrates the results of rigid direct laryngoscopy and flexible tracheal endoscopy in
a patient w ith significant tracheal stenosis.

Vocal cord paralysis/dysfunction

In most cases, paralysis or dysfunction of the vocal cords is caused by
dysfunction of the recurrent laryngeal or vagus nerve innervating the larynx. Even
when no real alteration of the anatomy is present, this condition may cause many
of the same problems associated with bronchial and tracheal stenosis.

Infectious processes (eg, bacterial pneumonia, tuberculosis)

Infectious etiologies (eg, bacterial pneumonia and tuberculosis) include viral,
fungal, and bacterial infections. They are characterized by consolidation of the
affected part of the lung and filling of the alveolar air spaces with exudate,
inflammatory cells, and fibrin, leading to a decrease in oxygen exchange
(ventilation mismatch) and, in severe cases, to destruction of the lung parenchyma
(see the images below).

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Chest radiography of patient w ith miliary tuberculosis.

CT scan of chest of patient w ith chronic invasive aspergillosis. Note bilateral nodular infiltrate w ith
cavitations.

Micrographic picture of lung parenchyma show ing areas of necrosis w ith organizing pneumonia in
patient w ith Nocardia (hematoxylin and eosin). Image courtesy of Dr. Chad Stone.

Interstitial lung diseases

Interstitial lung diseases include conditions caused by drugs, autoimmune
processes, fibrotic diseases, organic and inorganic dust exposure, sarcoidosis,
lymphangioleiomyomatosis (LAM), histiocytosis X, vasculitis, pulmonary alveolar
proteinosis, and any other process that will cause reduced lung volumes due to an
alteration in lung parenchyma leading to ventilation-perfusion mismatch (see the
images below).

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CT scan of chest in patient w ith pulmonary alveolar proteinosis. Note classic "crazy pavement"
pattern of lungs.

CT scan of patient w ith usual interstitial pneumonia. Note interstitial infiltrates and honeycombing in
periphery of lungs.

Micrographic picture (hematoxylin and eosin stain) of lung w ith usual interstitial pneumonia. Note
alternating areas of normal lung, interstitial inflammation, fibrosis, and honeycomb change
(patchw ork appearance). Image courtesy of Dr. Chad Stone.

Malignancy
Malignancy is an uncontrolled cell growth of the tissue in the lungs or airways.
Depending on the location and severity of the malignancy, it may lead to any of the
above described anatomic changes.

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Chest radiography of patient w ith metastatic melanoma to lungs. Note bilateral nodules
(metastasis).

CT scan of chest in the same patient as preceding image w ith metastatic melanoma of lungs.

Contributor Information and Disclosures

Author
Eduardo A Celis, MD Physician in Pulmonary and Critical Care Medicine, Interventional Pulmonology
Eduardo A Celis, MD is a member of the following medical societies: American Association for Bronchology
and Interventional Pulmonology, American College of Chest Physicians, American College of Physicians,
American Thoracic Society, Society of Critical Care Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Javier I Diaz-Mendoza, MD Senior Staff Physician, Interventional Pulmonology, Division of Pulmonary and
Critical Care Medicine, Henry Ford Hospital
Javier I Diaz-Mendoza, MD is a member of the following medical societies: American College of Chest
Physicians, American Thoracic Society, American Association for Bronchology and Interventional Pulmonology
Disclosure: Nothing to disclose.
Chief Editor
Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care
Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild
Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of
Medicine
Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest
Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic
Society
Disclosure: Nothing to disclose.

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