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Lung

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Lung
Lungs diagram detailed.svg
Diagram of the human lungs with the respiratory tract visible, and different colours for each lobe
Heart-and-lungs.jpg
The human lungs flank the heart and great vessels in the chest cavity
Details
System Respiratory system
Identifiers
Latin pulmo
Greek πνεύμων (pneumon)
MeSH A04.411
TA A06.5.01.001
FMA 68877
Anatomical terminology

The lungs are the primary organs of respiration in humans and many other animals including a few fish and some snails. In mammals and most other vertebrates, two lungs are located near the backbone on either side of the heart. Their function in the respiratory system is to extract oxygen from the atmosphere and transfer it into the bloodstream, and to release carbon dioxide from the bloodstream into the atmosphere, in a process of gas exchange. Respiration is driven by different muscular systems in different species. Mammals, reptiles and birds use their musculoskeletal systems to support and foster breathing. In early tetrapods, air was driven into the lungs by the pharyngeal muscles via buccal pumping, a mechanism still seen in amphibians. In humans, the primary muscle that drives breathing is the diaphragm. The lungs also provide airflow that makes vocal sounds including human speech possible.

Humans have two lungs, a right lung and a left lung. They are situated within the thoracic cavity of the chest. The right lung is bigger than the left, which shares space in the chest with the heart. The lungs together weigh approximately 1.3 kilograms (2.9 lb), and the right is heavier. The lungs are part of the lower respiratory tract that begins at the trachea and branches into the bronchi and bronchioles and which receive air breathed in via the conducting zone. These divide until air reaches microscopic alveoli, where gas exchange takes place. Together, the lungs contain approximately 2,400 kilometres (1,500 mi) of airways and 300 to 500 million alveoli. The lungs are enclosed within the pleural sac which allows the inner and outer walls to slide over each other whilst breathing takes place, without much friction. This sac encloses each lung and also divides each lung into sections called lobes. The right lung has three lobes and the left has two. The lobes are further divided into bronchopulmonary segments and lobules. The lungs have a unique blood supply, receiving deoxygenated blood sent from the heart for the purposes of receiving oxygen (the pulmonary circulation) and a separate supply of oxygenated blood (the bronchial circulation).

The tissue of the lungs can be affected by a number of diseases, including pneumonia and lung cancer. Chronic diseases such as chronic obstructive pulmonary disease and emphysema can be related to smoking or exposure to harmful substances. Diseases such as bronchitis can also affect the respiratory tract. Medical terms related to the lung often begin with pulmo-, from the Latin pulmonarius (of the lungs) as in pulmonology, or with pneumo- (from Greek πνεύμων "lung") as in pneumonia.

In embryonic development, the lungs begin to develop as an outpouching of the foregut, a tube which goes on to form the upper part of the digestive system. When the lungs are formed the fetus is held in the fluid-filled amniotic sac and so they do not function to breathe. Blood is also diverted from the lungs through the ductus arteriosus. At birth however, air begins to pass through the lungs, and the diversionary duct closes, so that the lungs can begin to respire. The lungs only fully develop in early childhood.

Structure of the human lungs[edit]

"Meet the lungs" from the Khan academy

Gross anatomy[edit]

Illu bronchi lungs.jpg

The lungs are located in the chest on either side of the heart in the rib cage. They are conical in shape with a narrow rounded apex at the top, and a broad concave base that rests on the convex surface of the diaphragm.[1] The apex of the lung extends into the root of the neck, reaching shortly above the level of the sternal end of the first rib. The lungs stretch from close to the backbone in the rib cage to the front of the chest and downwards from the lower part of the trachea to the diaphragm.[1] The left lung shares space with the heart, and has an indentation in its border called the cardiac notch of the left lung to accommodate this.[2][3] The front and outer sides of the lung face the ribs, which make light indentations on their surfaces. The medial surfaces of the lungs face towards the centre of the chest, and lie against the heart, great vessels, and the carina where the trachea divides into the two main bronchi.[3] The cardiac impression is an indentation formed on the surfaces of the lungs where they rest against the heart.

Both lungs have a central recession called the hilum at the root of the lung, where the blood vessels and airways pass into the lungs.[1] There are also bronchopulmonary lymph nodes on the hilum.[3]

The lungs are surrounded by the pulmonary pleurae. The pleurae are two serous membranes; the outer parietal pleura lines the inner wall of the rib cage and the inner visceral pleura directly lines the surface of the lungs. Between the pleurae is a potential space called the pleural cavity containing a thin layer of lubricating pleural fluid. Each lung is divided into lobes by the invaginations of the pleura as fissures. The fissures are double folds of pleura that section the lungs and help in their expansion.[4]

The lobes of the lungs are further divided into bronchopulmonary segments based on the locations of bronchioles. Segments for the left and right lung are shown in the table.[5] The segmental anatomy is useful clinically for localising disease processes in the lungs.[5]

Right lung[edit]

Lobes and bronchopulmonary segments [5]
Right lung Left lung
Upper
  • Apical
  • Anterior
  • Posterior
Middle
  • Medial
  • Lateral
Lower
  • Superior
  • Anterior
  • Posterior
  • Medial
  • Lateral
Upper
  • Anterior
  • Apicoposterior

Lower

  • Superior
  • Anterior
  • Posterior
  • Medial
  • Lateral

Lingula

  • Superior
  • Inferior

The right lung has both more lobes and segments than the left. It is divided into three lobes, an upper, middle, and a lower, by two fissures, one oblique and one horizontal. The upper, horizontal fissure, separates the upper from the middle lobe. It begins in the lower oblique fissure near the posterior border of the lung, and, running horizontally forward, cuts the anterior border on a level with the sternal end of the fourth costal cartilage; on the mediastinal surface it may be traced backward to the hilum.[1]

The lower, oblique fissure, separates the lower from the middle and upper lobes, and is closely aligned with the oblique fissure in the left lung.[1][4]

The mediastinal surface of the right lung is indented by a number of nearby structures. The heart sits in an impression called the cardiac impression. Above the hilum of the lung is an arched groove for the azygos vein, and above this is a wide groove for the superior vena cava and right innominate vein; behind this, and close to the top of the lung is a groove for the innominate artery. There is a groove for the esophagus behind the hilum and the pulmonary ligament, and near the lower part of the esophageal groove is a deeper groove for the inferior vena cava before it enters the heart.[3]

Left lung[edit]

The left lung is divided into two lobes, an upper and a lower, by the oblique fissure, which extends from the costal to the mediastinal surface of the lung both above and below the hilum.[1] The left lung, unlike the right, does not have a middle lobe, though it does have a homologous feature, a projection of the upper lobe termed the “lingula”. Its name means “little tongue”. The lingula on the left serves as an anatomic parallel to the right middle lobe, with both areas being predisposed to similar infections and anatomic complications.[6][7] There are two bronchopulmonary segments of the lingula: superior and inferior.[1]

The mediastinal surface of the left lung has a large cardiac impression where the heart sits. This is deeper and larger than that on the right lung, at which level the heart projects to the left.[3]

On the same surface, immediately above the hilum, is a well-marked curved groove for the aortic arch, and a groove below it for the descending aorta. The left subclavian artery, a branch off the aortic arch, sits in a groove from the arch to near the apex of the lung. A shallower groove in front of the artery and near the edge of the lung, lodges the left innominate vein. The esophagus may sit in a wider shallow impression at the base of the lung.[3]

The left lung
The right lung
The left lung (left) and right lung (right). The lobes of the lungs can be seen, and the central root of the lung is also present.

Respiratory system[edit]

Diagram of the respiratory system, which includes the upper respiratory tract and lower respiratory tract, of which the lungs are the major part.

The lower respiratory tract is part of the respiratory system, and consists of the trachea and the structures below this including the lungs.[8] The trachea receives air from the pharynx and travels down to a place where it splits (the carina) into a right and left bronchus. These supply air to the right and left lungs, splitting progressively into the secondary and tertiary bronchi for the lobes of the lungs, and into smaller and smaller bronchioles until they become the respiratory bronchioles. These in turn supply air through alveolar ducts into the alveoli, where the exchange of gases take place.[8] Oxygen breathed in, diffuses through the walls of the alveoli into the enveloping capillaries and into the circulation,[9] and carbon dioxide diffuses into the lungs to be breathed out.

Estimates of the total surface area of lungs vary from 50 to 75 square metres (540 to 810 sq ft);[8][10] roughly the same area as one side of a tennis court.[10][11]

The bronchi in the conducting zone are reinforced with hyaline cartilage in order to hold open the airways. The bronchioles have no cartilage and are surrounded instead by smooth muscle.[10] Air is warmed to 37 °C (99 °F), humidified and cleansed by the conducting zone; particles from the air being removed by the cilia on the respiratory epithelium lining the passageways.[12]

Blood supply[edit]

The lungs have a dual blood supply[8] provided by a bronchial and a pulmonary circulation. The tissues of the airways, like the other tissues of the body, are perfused by normal systemic arterial blood. This blood constitutes the bronchial circulation which arrives via the bronchial arteries that leave the aorta. There are usually three arteries, two to the left lung and one to the right, and they branch alongside the bronchi and bronchioles.[8]

Most of the blood flowing through the lungs forms the pulmonary circulation. This arrives in the lungs via the pulmonary arteries from the right side of the heart.[8] This blood is then spread to the pulmonary alveolar capillaries where the blood gases equilibrate with those in the alveolar air. The pulmonary capillary blood then drains into the pulmonary veins which return the blood to the left side of the heart, from where it is evenly spread to all parts of the body. The pulmonary circulation is in series with the systemic circulation, which means that the rate of blood flow, in litres per minute through the lungs, is equal to the rate of blood flow through the rest of the body.

The blood volume of the lungs, at any given moment, is about 450 millilitres on average, about 9 per cent of the total blood volume of the entire circulatory system. This quantity can easily fluctuate from between one-half and twice the normal volume.[13]

Nerve supply[edit]

The lungs are supplied by nerves of the autonomic nervous system. Input from the parasympathetic nervous system occurs via the vagus nerve. When stimulated by acetylcholine, this causes constriction of the smooth muscle lining the bronchus and bronchioli, and increases the secretions from glands.[14] The lungs also have a sympathetic tone from norepinephrine acting on the beta 2 receptors in the respiratory tract, which causes bronchodilation.[14]

The action of breathing takes place because of nerve signals sent by the respiratory centres in the brainstem, along the phrenic nerve to the diaphragm. This is described in more detail below.[15]

Microanatomy[edit]

Lung tissue
A respiratory lobule, the functional unit of the lung

The lungs contain the respiratory tract and its lining, which terminate in alveoli, the lung tissue in between, and veins, arteries, nerves and lymphatic vessels.[3][16]

The lower respiratory tract begins with the trachea and bronchi. These structures are lined with columnar epithelial cells that possess cilia, small frond-like projections. Interspersed with the epithelial cells are goblet cells which produce mucus, and club cells with actions similar to macrophages. Surrounding these in the trachea and bronchi are cartilage rings, which help to maintain stability.[10] Bronchioles possess the same columnar epithelial lining, but are not surrounded by cartilage rings. Instead, they are encircled by a layer of smooth muscle.[10] The respiratory tract ends in lobules. These consist of a respiratory bronchiole, which branches into alveolar ducts and alveolar sacs, which in turn divide into alveoli.[3]

The epithelial cells throughout the respiratory tract secrete epithelial lining fluid (ELF), the composition of which is tightly regulated and determines how well mucociliary clearance works.[17][18]:Section 4 pages 7–8 (Page 4–7ff) which in turn is coated with a layer of surfactant.[8]

Cross-sectional detail of the lung

Alveoli consist of two types of alveolar cell and an alveolar macrophage. The two types of cell are known as type I and type II alveolar cells[8] (also known as pneumocytes).[3] Types I and II make up the walls and alveolar septa. Type I cells provide 95% of the surface area of each alveoli and are flat ("squamous"), and Type II cells generally cluster in the corners of the alveoli and have a cuboidal shape.[10] Despite this, cells occur in a roughly equal ratio of 1:1 or 6:4.[8][10]

Type I are squamous epithelial cells that make up the alveolar wall structure. They have extremely thin walls that enable an easy gas exchange.[8] These type I cells also make up the alveolar septa which separate each alveolus. The septa consist of an epithelial lining and associated basement membranes.[10] Type I cells are not able to divide, and consequently rely on differentiation from Type II cells.[10]

Type II are larger and they line the alveoli and produce and secrete ELF and surfactant.[8] Type II cells are able to divide and differentiate to Type 1 cells.[10]

The alveolar macrophages have an important immunological role. They remove substances which deposit in the alveoli including loose red blood cells that have been forced out from blood vesels.[10]

The lung is surrounded by a serous membrane of visceral pleura, which has an underlying layer of loose connective tissue attached to the substance of the lung.[19]

Development[edit]

The development of the human lungs arise from the laryngotracheal groove and develop to maturity over several weeks in the foetus and for several months following birth.[20] The larynx, trachea, bronchi and lungs begin to form during the fourth week of embryogenesis[21] from the respiratory bud which appears ventrally to the caudal portion of the foregut.[22]

Lungs during development, showing primitive lung buds that have not yet fully divided into mature lungs.

At the end of the fourth week the lung bud divides into two, the right and left primary bronchial buds.[23] During the fifth week the right bud branches into three secondary bronchial buds and the left branches into two secondary bronchial buds. These give rise to the lobes of the lungs, three on the right and two on the left. Over the following week, the secondary buds branch into tertiary buds, about ten on each side.[23] From the sixth week to the sixteenth week, the major elements of the lungs appear except the alveoli.[24] From week 16 to week 26, the bronchi enlarge and lung tissue becomes highly vascularised. Bronchioles and alveolar ducts also develop. During the period covering the 26th week until birth the important blood–air barrier is established. Specialised type I alveolar cells where gas exchange will take place, together with the type II alveolar cells that secrete pulmonary surfactant, appear. The surfactant reduces the surface tension at the air-alveolar surface which allows expansion of the terminal saccules. These saccules form at the end of the bronchioles and their appearance marks the point at which limited respiration would be possible.[25]

First breath[edit]

At birth, the baby's lungs are filled with fluid secreted by the lungs and are not inflated. After birth its central nervous system reacts to the sudden change in temperature and environment. This triggers the first breath, within about 10 seconds after delivery.[26] Before birth, the lungs are filled with fetal lung fluid.[27] After the first breath, the fluid is quickly absorbed into the body or exhaled. The resistance in the lung's blood vessels decreases giving an increased surface area for gas exchange, and the lung begins to breathe spontaneously. This accompanies other changes which result in an increased amount of blood entering the lung tissues.[26]

At birth the lungs are very undeveloped with only a fraction of the alveoli present. The alveoli continue to form until the third year. Alveolar septa have a double capillary network instead of the single network of the developed lung. Only after the maturation of the capillary network can the lung enter a normal phase of growth. Following the early growth in numbers of alveoli there is another stage of the alveoli being enlarged.[28]

Function[edit]

Breathing[edit]

The effect of the respiratory muscles in expanding the rib cage.
The main muscles of forceful inhalation (left) and exhalation (right). Muscle contraction is indicated in red, relaxation in blue. When the diaphragm contracts it forces the abdominal contents downwards, causing the abdomen to bulge outwards, while the accessory muscles of inhalation increase the size of the rib cage (see illustration on the left). During forced exhalation the abdominal muscles decrease the volume of the chest cavity as shown. Exhalation at rest is entirely passive.

The lungs are not capable of expanding themselves, and will expand only when there is an increase in the volume of the thoracic cavity.[29] In humans, as in the other mammals, this is achieved primarily through the contraction of the diaphragm, but also by contraction the intercostal muscles which pull the rib cage upwards as shown in the diagrams on the left and right.[30] During exhalation (breathing out), at rest, the muscles of inhalation relax, returning the chest and abdomen to a position called the “resting position”, which is determined by their anatomical elasticity.[30] At this point the lungs contain the functional residual capacity of air, which, in the adult human, has a volume of about 2.5–3.0 litres.[30]

During heavy breathing (hyperpnoea), as, for instance, during exercise, a large number of additional muscles in the neck and abdomen are recruited during both inhalation and exhalation.[30] Exhalation, instead of being passive, is now caused by the rib cage being actively pulled downwards (front and sides) by the abdominal muscles, which not only decreases the size of the rib cage, but also pushes the abdominal organs upwards against the diaphragm which consequently bulges deeply into the thorax. The end-exhalatory lung volume is now less air than the resting "functional residual capacity".[30] However, in a normal mammal, the lungs cannot be emptied completely. In an adult human there is always still at least one litre of residual air left in the lungs after maximum exhalation.[30]

Gas exchange[edit]

An illustration of the process of gas exchange, emphasizing the differences between the gas compositions of the ambient air, the alveolar air (light blue) with which the pulmonary capillary blood equilibrates, and the blood gas tensions in the pulmonary arterial (blue blood entering the lung on the left) and venous blood (red blood leaving the lung on the right). All the gas tensions are in kPa. To convert to mm Hg, multiply by 7.5.
The changes in the composition of the alveolar air during a normal breathing cycle at rest. The scale on the left, and the blue line, indicate the partial pressures of carbon dioxide in kPa, while that on the right and the red line, indicate the partial pressures of oxygen, also in kPa (to convert kPa into mm Hg, multiply by 7.5).

The major function of the lungs is gas exchange between the blood gases and the alveolar air.[30] The alveolar and pulmonary capillary gases equilibrate across the blood–air barrier, a very thin diffusion membrane which is only, on average, about 2 μm thick,[31] consisting of the walls of the pulmonary alveoli, consisting of the alveolar epithelial cells, their basement membranes and the endothelial cells of the pulmonary capillaries.[30][31][32] This membrane is folded into about 300 million small air sacs called alveoli[31] (each between 75 and 300 µm in diameter) branching off from the bronchioles in the lungs, thus providing an extremely large surface area (estimates varying between 70 and 145 m2) for gas exchange to occur.[30][31]

The lungs of an average person at rest, and breathing normally contain between about 2.5 and 3.0 litres of alveolar air (the functional residual capacity). This semi-stagnant volume of air[note 1] that always remains in the lung alveoli after a normal exhalation is termed the functional residual capacity.[30] With each breath only about 350 ml (i.e. less than 15%) of this alveolar air is expelled into the ambient air (with about 150 ml remaining behind in the airways, as "dead space" ventilation, as it is the first air to re-enter the alveoli on inhalation).[30] This is immediately replaced with the same volume of fresh, but moistened, atmospheric air. It is therefore obvious that the 350 ml inhaled fresh air is highly diluted by the 3 litres of functional residual capacity air (i.e. the air that remains in the lungs after a normal exhalation), and that the composition of the alveolar air therefore changes very little under normal circumstances: the alveolar partial pressure of oxygen remains very close to 14 kPa ( 105 mmHg ), and that of carbon dioxide varies minimally around 5.3 kPa ( 40 mmHg ) throughout the respiratory cycle (of inhalation and exhalation).[30] Since the blood gasses in the alveolar capillaries equilibrate with those in the alveolar air, the arterial blood that is spread evenly throughout the body by the left ventricle, will have the same partial pressures of oxygen and carbon dioxide as persist in the alveoli.[30]

Control of breathing[edit]

The arterial partial pressures of oxygen and carbon dioxide in the arterial blood are homeostatically controlled. A rise in the arterial partial pressure of carbon dioxide, and, to a lesser extent, a fall in the arterial partial pressure of oxygen, will reflexly cause deeper and faster breathing till the blood gas tensions return to normal.[30] The converse happens when the carbon dioxide tension falls, or, again to a lesser extent, the oxygen tension rises: the rate and depth of breathing are reduced till blood gas normality is restored.[30]

It is only as a result of accurately maintaining the composition of the 3 litres alveolar air that, with each breath, some carbon dioxide is discharged into the atmosphere and some oxygen is taken up from the outside air. If more carbon dioxide than usual has been lost by a short period of hyperventilation, breathing will be slowed down or halted until the alveolar partial pressure of carbon dioxide has returned to 5.3 kPa ( 40 mmHg ).[30] The opposite occurs after breath-holding.

The partial pressures of oxygen and carbon dioxide in the arterial blood are measured by the "peripheral blood gas chemoreceptors" – the aortic and carotid bodies, and the "central blood gas chemoreceptors" of the medulla oblongata of the brainstem. The peripheral chemoreceptors are more sensitive to the arterial partial pressure of oxygen than they are to the arterial partial pressure of carbon dioxide.[30] The central chemoreceptor is particularly sensitive to the pH of the cerebrospinal fluid, which is directly influenced by the partial pressure of carbon dioxide in the arterial blood.[30][33]

Information from the blood gas chemoreceptors is relayed to a series of interconnected nuclei which comprise the respiratory centres in the medulla oblongata and the pons of the brainstem.[30] This information determines the average rate of ventilation of the alveoli of the lungs, to keep the partial pressures of oxygen and carbon dioxide in the arterial blood constant. The respiratory centre does so via motor neurons which activate the muscles of respiration (in particular the diaphragm).[15]

Exercise also increases the respiratory rate, partly in response to the movement of the limbs detected by proprioceptors in the muscles and joints, an increase in body temperature, the release of adrenaline (epinephrine) from the adrenal glands, and from motor impulses originating from the cerebral cortex.[34]

Protection[edit]

The lungs possess several characteristics which protect against infection. The lung tract is lined by epithelia with hair-like projections called cilia that beat rhythmically and carry mucus. This mucociliary clearance is an important defence system against air-borne infection. The dust particles and bacteria in the inhaled air are caught in the mucosal surface of respiratory passages and are moved up towards the pharynx by the rhythmic upward beating action of the cilia.[10][35][36] The lining of the lung also secretes immunoglobulin A which protects against respiratory infections;[35] goblet cells secrete mucus[10] which also contains several antimicrobial compounds such as defensins, antiproteases, and antioxidates.[35] In addition, the lining of the lung also contains macrophages, immune cells which engulf and destroy debris and microbes that enter the lung in a process known as phagocytosis; and dendritic cells which present antigens to activate components of the adaptive immune system such as T-cells and B-cells.[35]

The size of the respiratory tract and the flow of air also protect the lungs from larger particles. Smaller particles deposit in the mouth and behind the mouth in the oropharynx, and larger particles are trapped in nasal hair after inhalation.[35]

Other[edit]

In addition to their function in respiration, the lungs also have a number of other functions. They are involved in maintaining homeostasis, helping in the regulation of blood pressure as part of the renin-angiotensin system. The inner lining of the blood vessels secretes angiotensin-converting enzyme (ACE) an enzyme that catalyses the conversion of angiotensin I to angiotensin II.[37] The lungs are involved in the blood's acid-base homeostasis by expelling carbon dioxide when breathing.[29][38]

The lungs also serve a protective role. Several blood-borne substances, such as a few types of prostaglandins, leukotrienes, serotonin and bradykinin, are excreted through the lungs.[37] Drugs and other substances can be absorbed, modified or excreted in the lungs.[29][39] The lungs filter out small blood clots from veins and prevent them from entering arteries and causing strokes.[38]

The lungs also play a pivotal role in speech by providing air and airflow for the creation of vocal sounds.[29][40] Lungs also provide the airflow that enables the expression of many emotions such as sighing, yawning, sobbing, laughing in humans[30] and the vocal sounds in other animals.

Clinical significance[edit]

Lungs can be affected by a variety of diseases. Pulmonology is the medical speciality that deals with diseases involving the respiratory tract,[41] and cardiothoracic surgery is the surgical field that deals with surgery of the lungs.[42]

Inflammatory conditions of the lung tissue are pneumonia, of the respiratory tract are bronchitis and bronchiolitis, and of the pleurae surrounding the lungs pleurisy. Inflammation is usually caused by infections due to bacteria or viruses. When the lung tissue is inflamed due to other causes it is called pneumonitis. One major cause of bacterial pneumonia is tuberculosis.[35] Chronic infections often occur in those with immunodeficiency and can include a fungal infection by Aspergillus fumigatus that can lead to an aspergilloma forming in the lung.[35][43]

Infarction of the lung due to a pulmonary embolism

A pulmonary embolism is a blood clot that becomes lodged in the pulmonary arteries. The majority of emboli arise because of deep vein thrombosis in the legs. Pulmonary emboli may be investigated using a ventilation/perfusion scan, a CT scan of the arteries of the lung, or blood tests such as the D-dimer.[35] Pulmonary hypertension describes an increased pressure at the beginning of the pulmonary artery that has a large number of differing causes.[35] Other rarer conditions may also affect the blood supply of the lung, such as granulomatosis with polyangiitis, which causes inflammation of the small blood vessels of the lungs and kidneys.[35]

A lung contusion is a bruise caused by chest trauma. It results in hemorrhage of the alveoli causing a build-up of fluid which can impair breathing, and this can be either mild or severe. The function of the lungs can also be affected by compression from fluid in the pleural cavity pleural effusion, or other substances such as air (pneumothorax), blood (hemothorax), or rarer causes. These may be investigated using a chest X-ray or CT scan, and may require the insertion of a surgical drain until the underlying cause is identified and treated.[35]

Lung tissue affected by emphysema using H&E stain

Asthma, chronic bronchitis, bronchiectasis and chronic obstructive pulmonary disease (COPD) are all obstructive lung diseases characterised by airway obstruction. This limits the amount of air that is able to enter alveoli because of constriction of the bronchial tree, due to inflammation. Obstructive lung diseases are often identified because of symptoms and diagnosed with pulmonary function tests such as spirometry. Many obstructive lung diseases are managed by avoiding triggers (such as dust mites or smoking), with symptom control such as bronchodilators, and with suppression of inflammation (such as through corticosteroids) in severe cases. One common cause of COPD and emphysema is smoking, and common causes of bronchiectasis include severe infections and cystic fibrosis. The definitive cause of asthma is not yet known.[35]

Some types of chronic lung diseases are classified as restrictive lung disease, because of a restriction in the amount of lung tissue involved in respiration. These include pulmonary fibrosis which can occur when the lung is inflamed for a long period of time. Fibrosis in the lung replaces functioning lung tissue with fibrous connective tissue. This can be due to a large variety of occupational diseases such as Coalworker's pneumoconiosis, autoimmune diseases or more rarely to a reaction to medication.[35]

Lung cancer can either arise directly from lung tissue or as a result of metastasis from another part of the body. There are two main types of primary tumour described as either small-cell or non-small-cell lung carcinomas. The major risk factor for cancer is smoking. Once a cancer is identified it is staged using scans such as a CT scan and a sample of tissue (a biopsy) is taken. Cancers may be treated by surgically removing the tumour, radiotherapy, chemotherapy or combinations thereof, or with the aim of symptom control.[35]Lung cancer screening is being recommended in the United States for high-risk populations.[44]

Congenital disorders include cystic fibrosis, pulmonary hypoplasia (an incomplete development of the lungs)[45]congenital diaphragmatic hernia, and infant respiratory distress syndrome caused by a deficiency in lung surfactant. An azygos lobe is a congenital anatomical variation which though usually without effect can cause problems in thoracoscopic procedures.[46]

Lung function testing[edit]

Lung volumes as described in the text.
A person doing a spirometry test.

Lung function testing is carried out by evaluating a person's capacity to inhale and exhale in different circumstances.[47] The inhaled and exhaled by a person at rest is the tidal volume (normally 500-750mL); the inspiratory reserve volume and expiratory reserve volume are the additional amounts a person is able to forcibly inhale and exhale respectively. The summed total of forced inspiration and expiration is a person's vital capacity. Not all air is expelled from the lungs even after a forced breath out; the remainder of the air is called the residual volume. Together these terms are referred to as lung volumes.[47]

Pulmonary plethysmographs are used to measure functional residual capacity.[48] Functional residual capacity cannot be measured by tests that rely on breathing out, as a person is only able to breathe a maximum of 80% of their total functional capacity.[49] The total lung capacity depends on the person's age, height, weight, and sex, and normally ranges between 4 and 6 litres.[47] Females tend to have a 20–25% lower capacity than males. Tall people tend to have a larger total lung capacity than shorter people. Smokers have a lower capacity than nonsmokers. Thinner persons tend to have a larger capacity, and capacity can be increased by physical training as much as 40%.[49]

Other lung function tests include spirometry, measuring the amount (volume) and flow of air that can be inhaled and exhaled. The maximum volume of breath that can be exhaled is called the vital capacity. In particular, how much a person is able to exhale in one second (called forced expiratory volume (FEV1) as a proportion of how much they are able to exhale in total (FEV). This ratio, the FEV1/FEV ratio, is important to distinguish whether a lung disease is restrictive or obstructive.[35][47] Another test is that of the lung's diffusing capacity – this is a measure of the transfer of gas from air to the blood in the lung capillaries.

Other animals[edit]

Birds[edit]

A diagrammatic representation of the cross-current respiratory gas exchanger in the lungs of birds. Air is forced from the air sacs unidirectionally (from right to left in the diagram) through the parabronchi. The pulmonary capillaries surround the parabronchi in the manner shown (blood flowing from below the parabronchus to above it in the diagram).[50][51] Blood or air with a high oxygen content is shown in red; oxygen-poor air or blood is shown in various shades of purple-blue.
On inhalation, air travels to air sacs near the back of a bird. The air then passes through the lungs to air sacs near the front of the bird, from where the air is exhaled.

The lungs of birds are relatively small, but are connected to 8–9 air sacs that extend through much of the body, and are in turn connected to air spaces within the bones. On inhalation, air travels through the trachea of a bird into the 8–9 air sacs. Air then travels continuously from the air sacs at the back, through the lungs, which are relatively fixed in size, to the air sacs at the front. From here, the air is exhaled. These fixed size lungs are called "circulatory lungs", as distinct from the "bellows-type lungs" found in most other animals.[50][52]

The lungs of birds contain millions of tiny parallel passages called parabronchi. Small sacs called atria radiate from the walls of the tiny passages, and are the site of gas exchange by simple diffusion.[52] The blood flow around the parabronchi (and their atria), forms a cross-current gas exchanger (see diagram on the right).[50][51]

The partial pressure of O2 () in the parabronchioles declines along their length as O2 diffuses into the blood. The capillaries leaving the exchanger near the entrance of airflow take up more O2 than capillaries leaving near the exit end of the parabronchi. When the contents of all capillaries mix, the final of the mixed pulmonary venous blood is higher than that of the exhaled air,[50][51] but is nevertheless less half that of the inhaled air,[50] thus achieving roughly the same systemic arterial blood as mammals do with their bellows-type lungs.[50]

The air sacs, which hold air, do not contribute much to gas exchange, despite being thin-walled, as they are poorly vascularised. The air sacs expand and contract due to changes in the volume in the thorax and abdomen. This volume change is caused by the movement of the sternum and ribs and this movement is often synchronised with movement of the flight muscles.[53]

Parabronchi in which the air flow is unidirectional are called paleopulmonic parabronchi and are found in all birds. Some birds, however, have, in addition, a lung structure where the air flow in the parabronchi is bidirectional. These are termed neopulmonic parabronchi.[52]

Reptiles[edit]

The lung of most reptiles has a single bronchus running down the centre, from which numerous branches reach out to individual pockets throughout the lungs. These pockets are similar to alveoli in mammals, but much larger and fewer in number. These give the lung a sponge-like texture. In tuataras, snakes, and some lizards, the lungs are simpler in structure, similar to that of typical amphibians.[53]

Snakes and limbless lizards typically possess only the right lung as a major respiratory organ; the left lung is greatly reduced, or even absent. Amphisbaenians, however, have the opposite arrangement, with a major left lung, and a reduced or absent right lung.[53]

Both crocodilians and monitor lizards have developed lungs similar to those of birds, providing an unidirectional airflow and even possessing air sacs.[54] The now extinct pterosaurs have seemingly even further refined this type of lung, extending the airsacs into the wing membranes and, in the case of lonchodectids, tupuxuara, and azhdarchoids, the hindlimbs.[55]

Reptilian lungs typically receive air via expansion and contraction of the ribs driven by axial muscles and buccal pumping. Crocodilians also rely on the hepatic piston method, in which the liver is pulled back by a muscle anchored to the pubic bone (part of the pelvis), which in turn pulls the bottom of the lungs backward, expanding them. Turtles, which are unable to move their ribs, instead use their forelimbs and pectoral girdle to force air in and out of the lungs.[53]

Amphibians[edit]

Axolotl
The axolotl (Ambystoma mexicanum) retains its larval form with gills into adulthood

The lungs of most frogs and other amphibians are simple and balloon-like, with gas exchange limited to the outer surface of the lung. This is not very efficient, but amphibians have low metabolic demands and can also quickly dispose of carbon dioxide by diffusion across their skin in water, and supplement their oxygen supply by the same method. Amphibians employ a positive pressure system to get air to their lungs, forcing air down into the lungs by buccal pumping. This is distinct from most higher vertebrates, who use a breathing system driven by negative pressure where the lungs are inflated by expanding the rib cage.[56] In buccal pumping, the floor of the mouth is lowered, filling the mouth cavity with air. The throat muscles then presses the throat against the underside of the skull, forcing the air into the lungs.[57]

Due to the possibility of respiration across the skin combined with small size, all known lungless tetrapods are amphibians. The majority of salamander species are lungless salamanders, which respirate through their skin and tissues lining their mouth. This necessarily restrict their size: all are small and rather thread-like in appearance, maximising skin surface relative to body volume.[58] Other known lungless tetrapods are the Bornean flat-headed frog[59] and Atretochoana eiselti, a caecilian.[60]

The lungs of amphibians typically have a few narrow internal walls (septa) of soft tissue around the outer walls, increasing the respiratory surface area and giving the lung a honey-comb appearance. In some salamanders even these are lacking, and the lung has a smooth wall. In caecilians, as in snakes, only the right lung attains any size or development.[53]

Lungfish[edit]

The lungs of lungfish are similar to those of amphibians, with few, if any, internal septa. In the Australian lungfish, there is only a single lung, albeit divided into two lobes. Other lungfish and Polypterus, however, have two lungs, which are located in the upper part of the body, with the connecting duct curving around and above the esophagus. The blood supply also twists around the esophagus, suggesting that the lungs originally evolved in the ventral part of the body, as in other vertebrates.[53]

Invertebrates[edit]

Book lungs of spider (shown in pink)

Some invertebrates have "lungs" that serve a similar respiratory purpose as, but are not evolutionarily related to, vertebrate lungs. Some arachnids, spiders and scorpions, have structures called "book lungs" used for atmospheric gas exchange. Some species of spider have four pairs of book lungs but most have two pairs.[61] Scorpions have spiracles on their body for the entrance of air to the book lungs.[62]

The coconut crab is terrestrial and uses structures called branchiostegal lungs to breathe air.[63] They cannot swim and would drown in water, yet they possess a rudimentary set of gills. They can breathe on land and hold their breath underwater.[64] The branchiostegal lungs are seen as a developmental adaptive stage from water-living to enable land-living, or from fish to amphibian.[65]

Pulmonates are mostly land snails and slugs that have developed a simple lung from the mantle cavity. An externally located opening called the pneumostome allows air to be taken into the mantle cavity lung.[66][67]

Evolutionary origins[edit]

The lungs of today's terrestrial vertebrates and the gas bladders of today's fish are believed to have evolved from simple sacs, as outpocketings of the esophagus, that allowed early fish to gulp air under oxygen-poor conditions.[68] These outpocketings first arose in the bony fish. In most of the ray-finned fish the sacs evolved into closed off gas bladders, while a number of carps, trouts, herrings, catfish, and eels have retained the physostome condition with the sack being open to the esophagus. In more basal bony fish, such as the gar, bichir, bowfin and the lobe-finned fish, the bladders have evolved to primarily function as lungs.[68] The lobe-finned fish gave rise to the land-based tetrapods. Thus, the lungs of vertebrates are homologous to the gas bladders of fish (but not to their gills).[69]

Foot note[edit]

  1. ^ Although the functional residual capacity is described here as a "semi-stagnant" volume of air, this is only true in the sense that a lake of water with a small inlet and outlet seems "stagnant" compared with the rest of river. In the case of the “functional residual capacity” the entire volume of trapped air (or the “lake” in the river analogy) is always thoroughly mixed with the incoming inhaled air. This is brought about by the microscopic subdivisions of the “functional residual capacity” into many millions of smaller, minute air sacs, the alveoli, into which the inhaled air enters turbulently. Under normal circumstances the "functional residual capacity" is far from "stagnant" but always represents a thoroughly stirred large volume of the stored air with a small amount of diluted (with water vapor) fresh inhaled air, after each in-breath.

See also[edit]

Further reading[edit]

References[edit]

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