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Updated: Aug 16, 2011

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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Lung Anatomy
Dynamic CT scan of chest during expiration in normal patient. See how anteroposterior diameter of the trachea decreases because of
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...
collapse of posterior wall.
Updated: Aug 16,
The tracheal wall 2011
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 with nomenclature.

CT scan of chest (coronal view). Trachea, main carina, and right mainstem bronchus with upper, middle, and lower lobe airways can be
seen. Left mainstem bronchus is also seen with upper lobe airway. Left lower lobe airway 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 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

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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
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

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 arrows show both major fissures.

Pulmonary vasculature

A close relation exists between the bronchial tree and the anatomy of the 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 airways 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

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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)
Lung Anatomy
lymph nodes. However, some variants of the lymphatic drainage are very important to consider overall in the
dissemination of pulmonary neoplasms (see Pathophysiologic Variants).
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

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

CT scan of chest (coronal view) showing 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 showing 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.

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Lung Anatomy
Author:
Microscopic Javier
picture I Diaz, MD;
of bronchus Chief Editor:
(hematoxylin Zab stain).
and eosin Mosenifar, MD more...
Note mucosal layer with multiple goblet cells. Smooth muscle layer is in
periphery. Image courtesy of Dr. Chad Stone.
Updated: Aug 16, 2011
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 μ 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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Lung Anatomy
CT scan of chest in patient with congenital third fissure in right lung. Abnormal fissure is seen below major fissure in right.

Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

Azygous lobe. This lobe was 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 with 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)

Congenital diaphragmatic hernia, with 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

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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).
Lung Anatomy
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

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

Microscopic picture of emphysematous lung (hematoxylin and eosin stain). Upper part of picture shows destruction of alveolar septa.
Lower part of picture shows 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 with spontaneous right pneumothorax. Red arrows delineate lung edge.

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CT scan of chest in same patient with spontaneous right pneumothorax.

Lung Anatomy
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

Chest radiography of patient with right pleural effusion.

CT scan of chest in same patient with right pleural effusion. Red arrows 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 with large left diaphragmatic hernia. Note bowel 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.

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Chest radiography of female patient with tracheal stenosis due to previous endotracheal intubation. Red arrows show area of narrowing
in trachea.

Lung Anatomy
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

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

CT scan of chest in patient with tracheal stenosis due to lung cancer. Yellow arrows show tumor invading lateral wall and growing into
trachea, causing stenosis. (T=tumor).

CT scan of chest of patient with endobronchial carcinoid tumor of right mainstem bronchus (red arrows) causing complete collapse of
right lung.

This video demonstrates the results of rigid direct laryngoscopy and flexible tracheal endoscopy in a patient with 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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Lung Anatomy
Chest radiography of patient with miliary tuberculosis.

Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

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

Micrographic picture of lung parenchyma showing areas of necrosis with organizing pneumonia in patient with 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).

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

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

Lung Anatomy
Author: Javier I Diaz, MD; Chief Editor: Zab Mosenifar, MD more...

Updated: Aug 16, 2011

Micrographic picture (hematoxylin and eosin stain) of lung with usual interstitial pneumonia. Note alternating areas of normal lung,
interstitial inflammation, fibrosis, and honeycomb change (patchwork 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.

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

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

Contributor Information and Disclosures

Author
Javier I Diaz, MD Senior Staff Physician, Interventional Pulmonology, Division of Pulmonary and Critical Care
Medicine, Henry Ford Hospital

Javier I Diaz, MD is a member of the following medical societies: American Association of Bronchology and
American College of Chest Physicians

Disclosure: Nothing to disclose.

Coauthor(s)
Eduardo A Celis, MD Fellow, Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital

Eduardo A Celis, MD is a member of the following medical societies: American College of Chest Physicians,

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American College of Physicians, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Lung Anatomy
Chief Editor
Zab Mosenifar, MD Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild
Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical
Author:
Center, Javier of
University I Diaz, MD; Chief
California, Editor: Zab
Los Angeles, Mosenifar,
David Geffen MD more...
School of Medicine
Updated: Aug 16, 2011
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians,
American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

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Indian J Chest Dis Allied Sci. Jul-Sep 2004;46(3):179-82. [Medline].

4. Gonlugur U, Efeoglu T, Kaptanoglu M, Akkurt I. Major anatomical variations of the tracheobronchial tree:
bronchoscopic observation. Anat Sci Int. Jun 2005;80(2):111-5. [Medline].

5. The Thorax. In: Clemente CD. Anatomy: A Regional Atlas of the Human Body. 2nd Ed. Baltimore, MD:
Urban & Schwarzenberg, Inc; 1981:Fig 115-93.

6. Ferguson MK. Thoracic Surgery Atlas. Philadelphia, PA: Saunders Elsevier; 2007:Chap 3-5.

7. Naidich DP, Webb WR, Granier PA, Harkin TJ, Gefter WB. Imaging of the Airways. Functional and
Radiological Correlations. Philadelphia, PA: Lippincott, Williams & Wilkins; 2005:Chap 2-5.

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