Lung

Development

The development of the human lungs arise from the laryngotracheal groove and develop to maturity over several weeks in the foetus and for several years following birth.

The larynx, trachea, bronchi and lungs that make up the respiratory tract, begin to form during the fourth week of embryogenesis from the lung bud which appears ventrally to the caudal portion of the foregut.

The respiratory tract has a branching structure, and is also known as the respiratory tree. In the embryo this structure is developed in the process of branching morphogenesis, and is generated by the repeated splitting of the tip of the branch. In the development of the lungs (as in some other organs) the epithelium forms branching tubes. The lung has a left-right symmetry and each bud known as a bronchial bud grows out as a tubular epithelium that becomes a bronchus. Each bronchus branches into bronchioles. The branching is a result of the tip of each tube bifurcating. The branching process forms the bronchi, bronchioles, and ultimately the alveoli. The four genes mostly associated with branching morphogenesis in the lung are the intercellular signalling protein – sonic hedgehog (SHH), fibroblast growth factors FGF10 and FGFR2b, and bone morphogenetic protein BMP4. FGF10 is seen to have the most prominent role. FGF10 is a paracrine signalling molecule needed for epithelial branching, and SHH inhibits FGF10. The development of the alveoli is influenced by a different mechanism whereby continued bifurcation is stopped and the distal tips become dilated to form the alveoli.

At the end of the fourth week, the lung bud divides into two, the right and left primary bronchial buds on each side of the trachea. 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. From the sixth week to the sixteenth week, the major elements of the lungs appear except the alveoli. From week 16 to week 26, the bronchi enlarge and lung tissue becomes highly vascularised. Bronchioles and alveolar ducts also develop. By week 26, the terminal bronchioles have formed which branch into two respiratory bronchioles. 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 alveolar sacs. The alveolar sacs contain the primitive alveoli that form at the end of the alveolar ducts, and their appearance around the seventh month marks the point at which limited respiration would be possible, and the premature baby could survive.

Vitamin A deficiency

The developing lung is particularly vulnerable to changes in the levels of vitamin A. Vitamin A deficiency has been linked to changes in the epithelial lining of the lung and in the lung parenchyma. This can disrupt the normal physiology of the lung and predispose to respiratory diseases. Severe nutritional deficiency in vitamin A results in a reduction in the formation of the alveolar walls (septa) and to notable changes in the respiratory epithelium; alterations are noted in the extracellular matrix and in the protein content of the basement membrane. The extracellular matrix maintains lung elasticity; the basement membrane is associated with alveolar epithelium and is important in the blood-air barrier. The deficiency is associated with functional defects and disease states. Vitamin A is crucial in the development of the alveoli which continues for several years after birth.

After birth

At birth, the baby's lungs are filled with fluid secreted by the lungs and are not inflated. After birth the infant's central nervous system reacts to the sudden change in temperature and environment. This triggers the first breath, within about ten seconds after delivery. Before birth, the lungs are filled with fetal lung fluid. 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 lungs begin to breathe spontaneously. This accompanies other changes which result in an increased amount of blood entering the lung tissues.

At birth, the lungs are very undeveloped with only around one sixth of the alveoli of the adult lung present. The alveoli continue to form into early adulthood, and their ability to form when necessary is seen in the regeneration of the lung. 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.

Function

Gas exchange

The major function of the lungs is gas exchange between the lungs and the blood. The alveolar and pulmonary capillary gases equilibrate across the thin blood–air barrier. This thin membrane (about 0.5 –2 μm thick) is folded into about 300 million alveoli, providing an extremely large surface area (estimates varying between 70 and 145 m²) for gas exchange to occur.

The lungs are not capable of expanding to breathe on their own, and will only do so when there is an increase in the volume of the thoracic cavity. This is achieved by the muscles of respiration, through the contraction of the diaphragm, and the intercostal muscles which pull the rib cage upwards as shown in the diagram. During breathing out the muscles relax, returning the lungs to their resting position. At this point the lungs contain the functional residual capacity (FRC) of air, which, in the adult human, has a volume of about 2.5–3.0 litres.

During heavy breathing as in exertion, a large number of accessory muscles in the neck and abdomen are recruited, that during exhalation pull the ribcage down, decreasing the volume of the thoracic cavity. The FRC is now decreased, but since the lungs cannot be emptied completely there is still about a litre of residual air left. Lung function testing is carried out to evaluate lung volumes and capacities.

Protection

The lungs possess several characteristics which protect against infection. The respiratory tract is lined by respiratory epithelium or respiratory mucosa, 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 the airways, and are moved up towards the pharynx by the rhythmic upward beating action of the cilia.

The lining of the lung also secretes immunoglobulin A which protects against respiratory infections; goblet cells secrete mucus which also contains several antimicrobial compounds such as defensins, antiproteases, and antioxidants. 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.

Other

In addition to their function in respiration, the lungs 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. The lungs are involved in the blood's acid–base homeostasis by expelling carbon dioxide when breathing.

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. Drugs and other substances can be absorbed, modified or excreted in the lungs. The lungs filter out small blood clots from veins and prevent them from entering arteries and causing strokes.

The lungs also play a pivotal role in speech by providing air and airflow for the creation of vocal sounds, and other paralanguage communications such as sighs and gasps.

Research suggests a role of the lungs in the production of blood platelets.

Gene and protein expression

About 20,000 protein coding genes are expressed in human cells and almost 75% of these genes are expressed in the normal lung. A little less than 200 of these genes are more specifically expressed in the lung with less than 20 genes being highly lung specific. The highest expression of lung specific proteins are different surfactant proteins, such as SFTPA1, SFTPB and SFTPC, and napsin, expressed in type II pneumocytes. Other proteins with elevated expression in the lung are the dynein protein DNAH5 in ciliated cells, and the secreted SCGB1A1 protein in mucus-secreting goblet cells of the airway mucosa.

Clinical significance

Lungs can be affected by a number of diseases and disorders. Pulmonology is the medical speciality that deals with respiratory diseases involving the lungs and respiratory system. Cardiothoracic surgery deals with surgery of the lungs including lung volume reduction surgery, lobectomy, pneumectomy and lung transplantation.

Inflammation and infection

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. 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. In the US certain species of rat can transmit a hantavirus to humans that can cause untreatable hantavirus pulmonary syndrome with a similar presentation to that of acute respiratory distress syndrome (ARDS).

Alcohol affects the lungs and can cause inflammatory alcoholic lung disease. Acute exposure to alcohol stimulates the beating of cilia in the respiratory epithelium. However, chronic exposure has the effect of desensitising the ciliary response which reduces mucociliary clearance (MCC). MCC is an innate defense system protecting against pollutants and pathogens, and when this is disrupted the numbers of alveolar macrophages are decreased. A subsequent inflammatory response is the release of cytokines. Another consequence is the susceptibility to infection.

Blood-supply changes

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. Pulmonary hypertension describes an increased pressure at the beginning of the pulmonary artery that has a large number of differing causes. 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.

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.

Obstructive lung diseases

Asthma, bronchiectasis, and chronic obstructive pulmonary disease (COPD) that includes chronic bronchitis, and emphysema, 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. A common cause of chronic bronchitis, and emphysema, is smoking; and common causes of bronchiectasis include severe infections and cystic fibrosis. The definitive cause of asthma is not yet known, but it has been linked to other atopic diseases.

The breakdown of alveolar tissue, often as a result of tobacco-smoking leads to emphysema, which can become severe enough to develop into COPD. Elastase breaks down the elastin in the lung's connective tissue that can also result in emphysema. Elastase is inhibited by the acute-phase protein, alpha-1 antitrypsin, and when there is a deficiency in this, emphysema can develop. With persistent stress from smoking, the airway basal cells become disarranged and lose their regenerative ability needed to repair the epithelial barrier. The disorganised basal cells are seen to be responsible for the major airway changes that are characteristic of COPD, and with continued stress can undergo a malignant transformation. Studies have shown that the initial development of emphysema is centred on the early changes in the airway epithelium of the small airways. Basal cells become further deranged in a smoker's transition to clinically defined COPD.

Restrictive lung diseases

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 lung diseases such as Coalworker's pneumoconiosis, autoimmune diseases or more rarely to a reaction to medication. Severe respiratory disorders, where spontaneous breathing is not enough to maintain life, may need the use of mechanical ventilation to ensure an adequate supply of air.

Cancers

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 from a biopsy is taken. Cancers may be treated surgically by removing the tumour, the use of radiotherapy, chemotherapy or a combination, or with the aim of symptom control. Lung cancer screening is being recommended in the United States for high-risk populations.

Congenital disorders

Congenital disorders include cystic fibrosis, pulmonary hypoplasia (an incomplete development of the lungs)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.

Pleural space pressure

A pneumothorax (collapsed lung) is an abnormal collection of air in the pleural space that causes an uncoupling of the lung from the chest wall. The lung cannot expand against the air pressure inside the pleural space. An easy to understand example is a traumatic pneumothorax, where air enters the pleural space from outside the body, as occurs with puncture to the chest wall. Similarly, scuba divers ascending while holding their breath with their lungs fully inflated can cause air sacs (alveoli) to burst and leak high pressure air into the pleural space.

Examination

As part of a physical examination in response to respiratory symptoms of shortness of breath, and cough, a lung examination may be carried out. This exam includes palpation and auscultation. The areas of the lungs that can be listened to using a stethoscope are called the lung fields, and these are the posterior, lateral, and anterior lung fields. The posterior fields can be listened to from the back and include: the lower lobes (taking up three quarters of the posterior fields); the anterior fields taking up the other quarter; and the lateral fields under the axillae, the left axilla for the lingual, the right axilla for the middle right lobe. The anterior fields can also be auscultated from the front. An area known as the triangle of auscultation is an area of thinner musculature on the back which allows improved listening. Abnormal breathing sounds heard during a lung exam can indicate the presence of a lung condition; wheezing for example is commonly associated with asthma and COPD.

Function testing

Lung function testing is carried out by evaluating a person's capacity to inhale and exhale in different circumstances. The volume of air inhaled and exhaled by a person at rest is the tidal volume (normally 500–750 mL); 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.

Pulmonary plethysmographs are used to measure functional residual capacity. 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. The total lung capacity depends on the person's age, height, weight, and sex, and normally ranges between four and six litres. 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. Lung capacity can be increased by physical training as much as 40% but the effect may be modified by exposure to air pollution.

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. 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.

Culinary uses

Mammal lung is one of the main types of offal, or pluck, alongside the heart and trachea, and is consumed as a foodstuff around the world in dishes such as Scottish haggis. The United States Food and Drug Administration legally prohibits the sale of animal lungs due to concerns such as fungal spores or cross-contamination with other organs, although this has been criticised as unfounded.

Other animals

Birds

The lungs of birds are relatively small, but are connected to eight or nine 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 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.

The lungs of birds contain millions of tiny parallel passages called parabronchi. Small sacs called atria radiate from the walls of the tiny passages; these, like the alveoli in other lungs, are the site of gas exchange by simple diffusion. The blood flow around the parabronchi and their atria forms a cross-current process of gas exchange (see diagram on the right).

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.

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.

Reptiles

The lungs of most reptiles have 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.

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.

Both crocodilians and monitor lizards have lungs similar to those of birds, providing a unidirectional airflow and even possessing air sacs. 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.

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) called the diaphragmaticus, which in turn creates negative pressure in the crocodile's thoracic cavity, allowing air to be moved into the lungs by Boyle's law. Turtles, which are unable to move their ribs, instead use their forelimbs and pectoral girdle to force air in and out of the lungs.

Amphibians

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. 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.

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 restricts their size: all are small and rather thread-like in appearance, maximising skin surface relative to body volume. Another known lungless tetrapod is Atretochoana eiselti, a caecilian.

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 honeycomb 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.

Fish

Lungs are found in three groups of fish; the coelacanths, the bichirs and the lungfish. Like in tetrapods, but unlike fish with swim bladder, the opening is at the ventral side of the oesophagus. The coelacanth has a nonfunctional and unpaired vestigial lung surrounded by a fatty organ. Bichirs, the only group of ray-finned fish with lungs, have a pair which are hollow unchambered sacs, where the gas-exchange occurs on very flat folds that increase their inner surface area. The lungs of lungfish show more resemblance to tetrapod lungs. There is an elaborate network of parenchymal septa, dividing them into numerous respiration chambers. In the Australian lungfish, there is only a single lung, albeit divided into two lobes. Other lungfish, however, have traditionally been considered having two lungs, but newer research defines paired lungs as bilateral lung buds that arise simultaneously and are both connected directly to the foregut, which is only seen in tetrapods. In all lungfish, including the Australian, the lungs are located in the upper dorsal part of the body, with the connecting duct curving around and above the oesophagus. The blood supply also twists around the oesophagus, suggesting that the lungs originally evolved in the ventral part of the body, as in other vertebrates.

Invertebrates

A number of invertebrates have lung-like structures that serve a similar respiratory purpose to true vertebrate lungs, but are not evolutionarily related and only arise out of convergent evolution. Some arachnids, such as 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. Scorpions have spiracles on their body for the entrance of air to the book lungs.

The coconut crab is terrestrial and uses structures called branchiostegal lungs to breathe air. Juveniles are released into the ocean, however adults cannot swim and possess an only rudimentary set of gills. The adult crabs can breathe on land and hold their breath underwater. The branchiostegal lungs are seen as a developmental adaptive stage from water-living to enable land-living, or from fish to amphibian.

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.

Evolutionary origins

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 oesophagus, that allowed early fish to gulp air under oxygen-poor conditions. 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 carp, trout, herring, catfish, and eels have retained the physostome condition with the sac being open to the oesophagus. In more basal bony fish, such as the gar, bichir, bowfin and the lobe-finned fish, the sacs have evolved to primarily function as lungs. 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).