generalized bronchiectasis associated deficiency of ... · generalized bronchiectasis fibrocystic...

GENERALIZED BRONCHIECTASIS ASSOCIATED WITHDEFICIENCY OF CARTILAGE IN THE BRONCHIAL TREE

BY

HOWARD WILLIAMS and PETER CAMPBELLFrom the Departments of Clinical Research and Pathology, Royal Children's Hospital, Melbourne

(RECEIVED FOR PUBLICATION JULY 20, 1959)

Bronchiectasis may occasionally affect almost theentire bronchial tree. Such changes can be theresult either of developmental defects of the bron-chial tree or of acquired inflammatory disease. Forexample, cystic lung and cystic bronchiectasis canresult from both causes.The purpose of the present paper is to record five

patients with a most unusual type of generalizedbronchiectasis, and to submit evidence that its basisis deficiency of the cartilage of the bronchial walls,probably developmental in origin.

Material and Methods

The five patients have been studied clinically forperiods between three and nine years. Radio-logical, bronchoscopic, bronchographic and bacter-iological examinations have been carried out atsuitable intervals. The lungs of one of the twopatients who died were examined in the fresh stateand then fixed by injecting the bronchi with forma-lin. Studies consisted of macroscopic dissection ofseveral segmental bronchi and their divisions, andserial histological sections of four lung segments(apical, anterior and posterior basic and lingula ofthe left lung). The stains used were haematoxylinand eosin, Verhoeff van Gieson and periodic acidstain of Schiff. The bronchi were identifiednumerically by counting distally from the segmentalbronchus (Hayward and Reid, 1952); see Appendix.

Clinical Features

Case 1. J.G. In October, 1949, a boy aged 21 yearswas referred to the Royal Children's Hospital with acough, irregular fever and wheezy breathing, which

developed following an attack of morbilli six weekspreviously. Before this he was well and had no seriousillnesses. His doctor had made a diagnosis of unresolvedpneumonia and asthma, and had unsuccessfully treatedhim with antibiotics and antispasmodics. He was foundto be thin, with slightly cyanosed lips, and his breathingwas difficult and audibly wheezy. His chest was barrel-shaped, and inspiratory and expiratory rhonchi and finecrepitations were heard over the entire chest. A radio-graph of the chest showed prominent hilar shadows andbronchovascular markings, some haziness in the rightmiddle lobe and lingula and slight pulmonary emphy-sema. His Mantoux test 1:1000 OT was negative andStreptococcus viridans was grown from a small blob ofexpectorated mucopus. Bronchoscopic examinationwas normal apart from some muco-purulent secretion inboth bronchi. A remarkable bronchographic picturewas seen on the x-ray screen, the whole bronchial treefrom the first division of the segmental bronchus to thefifth or eighth division (depending on the size of thesegment) expanded and narrowed with inspiration andexpiration (Fig. la and b), while the fourth to sixth oreighth divisions of the right bronchial tree were like aseries of elongated balloons which were being inflatedand deflated (Fig. 2a and b). These changes were morepronounced in the right than in the left lung. At the siteof bronchial branching the movement was not so marked.Apart from one or two small areas, no oil entered the finedivisions of the bronchial tree, even though dye was stillpresent in the bronchial tree 40 hours later (Fig. 3aand b).Treatment with penicillin and sulphonamides and

postural coughing led to slight improvement in hisgeneral condition but the cough and wheeze persisted andhe periodically had attacks of fever and malaise. As hegrew older his symptoms lessened and his general healthimproved. Nine years after the onset he is in fairhealth but is unable to run without becoming very short-winded, has a constant slight inspiratory and expiratorywheeze and cough. His chest is barrel-shaped with apigeon deformity and Harrison's sulcus.

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FIG. la.-Case 1. J.G. Bronchogram in inspiration showing'cystic' dilatation of right bronchial tree and cylindrical dilatation

of left.

FIG. 2a.-Case 1. J.G. Bronchogram of right bronchial tree ininspiration showing gross bronchial dilatation beyond segmental

bronchi but no bronchiolar filling.

lb.-Case 1. J.G. Bronchogram in expiration, showingcollapse of bronchi.

FIG. 2b.-Case 1. J.G. Bronchogram of right bronchial tree inexpiration showing collapse of bronchi.



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FIG. 3a.-Case 1. J.G. Film in inspiration taken 40 hours afterFig. 2a showing retention of dye and no filling of small bronchi.

Case 2. D.S., the first baby of healthy parents, madenormal progress until the age of 10 months when hedeveloped a running nose, cough and wheezy breathing.A diagnosis of asthmatic bronchitis was made, buttreatment with antibiotics and antispasmodics failed torelieve his symptoms. The cough, wheezing and febrileattacks gradually became worse and his general healthdeteriorated.At the age of 2 years 8 months when he was admitted

to the Royal Children's Hospital in July 1952 he was illwith distressed wheezy breathing and slight cyanosis oflips and ears. He had a barrel-shaped chest with bilateralHarrison's sulcus, the air entry over the entire chest waspoor, and inspiratory and expiratory rhonchi and numer-ous fine crepitations were heard over the whole lungs. Theheart was displaced to the left and the percussion noteover the left upper lobe was impaired. The abdomenwas distended, the fingers clubbed and he expectoratedsome mucopus, culture of which grew Staphylococcusaureus. A chest radiograph showed collapse of the leftupper lobe and mediastinal shift to the left, and the peri-pheral lung field of the right lung and the left lower lobe

FIG. 3b.-Case 1. J.G. Film in expiration taken 40 hours afterFig. 2a showing collapse of bronchi.

appeared emphysematous. Bronchoscopy was normalapart from a small amount of mucopus in both bronchi.Bronchographic examination was almost identical withthat in Case 1, but the bronchiectatic changes were mostpronounced on the left side where the left lung wascollapsed. Expansion and partial collapse were observedfrom the first division of the segmental bronchus to thefifth or eighth division, according to the segment, but nodye entered the bronchiolar tree.

Treatment with antibiotics, antispasmodics andpostural coughing afforded only slight relief. Hiscondition gradually deteriorated and he died of respira-tory failure at the age of 3 years 2 months. Autopsywas refused.

Case 3. J.C. was a healthy baby of healthy parentsuntil she developed pink disease at the age of 14 months.She was left with a slight cough and occasionally had aslight wheeze. At the age of 2 years 3 months shedeveloped measles following which her cough becameworse, her breathing difficult and wheezy, her stools paleand offensive and her body wasted. A diagnosis of

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GENERALIZED BRONCHIECTASISfibrocystic disease of the pancreas was made. Followingtreatment with chemotherapy she very slowly improved.When seen at the Royal Children's Hospital in May

1953 at the age of 4 years she appeared in fair generalhealth, had a rather barrel-shaped chest, a slight wheezeand produced a little mucopus on posture. Impaired per-cussion note and tubular breathing were heard over theleft lower lobe and scattered crepitations over the entirechest. A radiograph of the chest showed increase in thebroncho-vascular markings, collapse of the left lower lobeand somewhat emphysematous peripheral lung fields.Duodenal enzymes and fat balance were normal.Bronchoscopy was normal apart from a little mucopus inthe left lower lobe bronchus. The bronchogram showedchanges similar to those in Cases 1 and 2 with theexception that in the right lower lobe and pectoralsegment of the left upper lobe the bronchial calibrechanges during respiration were not so pronounced andthere was filling of some of the smaller bronchi and thebronchiolar tree.From the age of 4 years up to 91 years she slowly and

steadily improved in general health. She has a veryslight cough at present and usually no sputum and onlywheezes and coughs sputum if she develops a cold or hasa feverish attack. These attacks used to occur every fewmonths but now she has them only occasionally. Shecan run but gets short of wind easily. A ventilatorycapacity test at the age of 9 years showed figures indica-tive of a moderately severe obstructive type of ventilatorydefect.

Case 4. A.D., a healthy baby of healthy parents,made normal progress until the age of 10 months whenshe contracted morbilli. After this she developed acough, rapid wheezy breathing and would not eat. Asthese symptoms persisted she was referred to the RoyalChildren's Hospital in November 1955 aged 1 year with adiagnosis of unresolved broncho-pneumonia. She wasmoderately well nourished, had slightly rapid labouredrespirations with an audible inspiratory and expiratorywheeze. Numerous inspiratory and expiratory rhonchiand fine crepitations were heard all over the chest. Aradiograph showed prominent bronchovascular markingsand some emphysema in the peripheral lung fields. Cul-ture of a cough swab yielded Staph. aureus and Proteus.Treatment with one of the tetracycline group of drugsresulted in some general improvement but the cough andwheeze persisted, she continued to run episodes of feverand her signs remained unchanged. Bronchoscopy atthe age of 2 years was normal apart from some mucopusin both bronchi. A bronchogram showed symmetricalexpansion and collapse of the bronchial tree from theregion of the first segmental divisions down to the fifthor eighth branching, according to the segment. Apartfrom a few areas the dye did not enter small bronchior bronchioles.During the two years follow-up her general health has

slowly improved. She still has a slight cough and anaudible inspiratory and expiratory wheeze, but duringthe last year has only had two mild feverish attacks. Herchest is deformed with a marked pigeon chest, bilateral

Harrison's sulcus and she breathes with the upper part.She becomes short-winded if she attempts to run.

Case 5. A.W., a premature baby weighing 4 lb. 7 oz.,developed a cough and wheeze at the age of 2i months.The cough and wheeze persisted, he ran frequent febrileepisodes and was said to be cyanosed at times. Whenfirst seen at the Royal Children's Hospital in December1952 at the age of 2i years he was a thin, poorly nour-ished child (weight 20 lb.) with slightly cyanosed lips andears. His breathing was difficult and there was a moder-ately loud inspiratory and expiratory wheeze. The chestwas barrel-shaped, movement being predominantly inthe upper portion, and numerous fine crepitations andrhonchi were heard all over the chest. No otherabnormalities were found. A radiograph of the chestshowed increased bronchovascular markings and veryfew vascular markings in the peripheral lung fields. HisMantoux test 1: 1000 OT was negative, his stools did notshow any fat globules and culture of a cough swabyielded Staph. aureus. Bronchoscopic examination wasnormal apart from some reddening of the bronchialmucosa and a small amount of purulent exudate in bothbronchi. The bronchogram showed that the segmentalbronchi down to the fifth or eighth divisions, accordingto the segment, dilated and narrowed with inspiration andexpiration (Fig. 4a and b), but not to the same degree asin the first three patients. Several areas in both lungsshowed some bronchiolar filling. Dye was still presentin the dilated bronchi 48 hours after instillation.During the next two years until his death at the age of

4 years 8 months he had a constant cough, increasinglydifficult breathing with cyanosis and frequent episodesof fever. Gradually he developed pulmonary hyper-tension, his heart enlarged, and an angiogram showedsome dilatation of the right auricle, right ventricle andpulmonary artery, while the pulmonary tree showedirregular tortuous small arterioles with delayed passageof dye. Cardiac catheterization showed moderatepulmonary hypertension.

Morbid Anatomical Features of Case 5

Pathological changes were confined to the respira-tory and cardiovascular systems. In the fresh statethe lungs appeared congested and felt nodular.Bronchi distal to the main segmental divisions weredilated and the mucosa of all bronchi was oedema-tous and inflamed. The pulmonary arteries weredilated and slightly atheromatous, and the heartshowed moderate hypertrophy and dilatation of theright ventricle. After formalin fixation furthermacroscopic and microscopic studies were carriedout.

Macroscopic Appearances. The segmental bron-chi were normal, but the second and third divisionswere dilated, being of similar calibre to the segmen-tal bronchus. Many of the dilated lateral divisionssuddenly tapered to a fine thread barely possessing

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FIG. 4a.-Case 5. A.W. Bronchogram showing bronchial dilata- FIG. 4b.-Case 5. A.W. Bronchogram showing collapse oftion in left lower lobe. Film in inspiration. bronchi in left lower lobe. Film in expiration.

a lumen. Divisions of theaxial bronchi distal to thethird division graduallytapered, but were still greatlydilated compared with thenormal controls (Fig. 5aand b). The most strikingfeature was the extreme soft-ness of the bronchial walls,which, despite formalin fixa-tion, were as flabby as bloodvessels. In nearly all of thebronchi dissected the trans-ition from firm rigid walls tosoft easily compressible struc-tures was sudden and occur-red along the course of thesecond or third division.From this point to the peri-phery the walls remained soft,except where division occur-red when a slight resistancecould be felt in the acuteangle of the bifurcation. Inseveral dissections it was

FIG. 5a.-Case 5. A.W. Dissection show-ing dilated bronchi, partly unroofed, oflingula and pectoral segments. (Slightly

reduced.)

FIG. 5b.-Dissection of normal anterior basicbronchus and its divisions. (Slightly reduced.)



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GENERALIZED BRONCHIECTASISdifficult to trace an axial bronchus to the periphery,bronchial branching being dichotomous and formingtwo divisions of identical calibre. In many instances,however, a true axial bronchus was present (seeAppendix).

Microscopical Findings. These were as follows.SEGMENTAL BRONCHI (FIRST DIVISION BRONCHI).

The mucosa showed pseudostratified ciliated colum-nar epithelium with areas of squamous metaplasia(mucosa less folded than normal) resting on anarrow condensed band of collagen 7-20[± in thick-ness. Foci of lymphocytes were present with littleapparent relation to the nature or state of the

mucosal cells (viz., pseudostratified, ciliated or non-ciliated, squamous metaplasia).

Muscle coat was present in all bronchi examined.It was very thin in places (30-40,u) but elsewhere wasquite thick (200-300,u). It was often thin next tocartilage plaques and thicker where cartilage wasabsent. Beneath the muscle and merging with itwas a network of collagen and elastic fibres, thickerand more prominent in areas deficient in cartilage.

Individual plaques of cartilage varied in size andappeared 'chunky', i.e. they were not long and thinas in the normal; in cross-section their sizevaried from700 ,u to 2,500 ,. and, as in the normal, their edgesmerged with the surrounding fibro-elastic network.

FIG. 6a.-Case 5. A.W. Longitudinal section of segmental bronchus showing cartilage distribution. (Note two bronchi arose out ofplane of section. Bronchial divisions are numbered.)

..........

..

FIG. 6b.-Longitudinal section of segmental bronchus showing cartilage distribution in the normal. Bronchial divisions are numbered.Three bronchi arose out of plane of section.

6

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188

FIG. 7a.-Case 5. A.W. Showingcomplete at

FIG. 7b.-Normal control, showic

SUB-SEGMENTAL BRONCHDiviSIONS). More numernmetaplasia were present in t

ARCHIVES OF DISEASE IN CHILDHOOD

One must distinguish betweenthe axial bronchus and its lateraldivisions, all lateral divisionsbeing devoid of cartilage whereasin occasional cases the third and

*!t 2| !=E leven fourth division axialbronchi contained isolatedcartilage plates. Thus, examina-tion of sections from theanterior basic bronchus (leftlung) showed cartilage distribu-tion as follows. The segmentalbronchus and the first, secondand third division bronchi con-

*X_ tained cartilage. In the thirddivision bronchi, the plaqueswere widely separated and were

a l small. In the fourth divisionbronchus, very occasionalplaques only were visible.

g a cross-section of a fifth division axial bronchus. Note Examination of the lingulabsence of cartilage in wall (x25) bronchus showed cartilage as far

down as the third division but itwas absent distal to this. Aother bronchi from the end ofthe second division showed wallsdevoid of cartilage except ateach point of bifurcation wherea small nub of cartilage waspresent in all cases down as faras the fifth, sixth and seventhdivision bronchi (Figs. 6a andb; 7a and b).The following changes were

_ _ .found in the more peripheralparts of the lungs. Bronchiolarobliteration was often severe andextensive (Fig. 8). Bronchioleswere far less numerous than inthe normal controls. Some that

_,y had been recently obliteratedwere still recognizable, but many

ng cross-section of fifth division axial bronchus. Note were represented only by small,artilage present. (x 25.) areas of scarring. Emphysema

was focal, related to obliterated1I (SECOND AND DISTAL bronchioles and moderately severe. Vascularous areas of squamous thickening was slight, involving the medium-sizedthe mucosa, otherwise the and small arterioles.1r-w- _ ~.... .----

pattern was similar to that in the segmental bronchus.Muscle was invariably present, sometimes thin

(30-40 ,u) but quite often normal in appearance andthickness. Isolated areas of small round cellinfiltration were present, some of which wereassociated with partial fibrous replacement ofmuscle.

DiscussionThe clinical features in all five children were very

similar. The disease commenced in infancy, eitherinsidiously as mild bronchitis or more acutely withmorbilli. Persistent cough, wheezy difficult breath-ing, recurrent febrile episodes and widespread



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GENERALIZED BRONCHIECTASIS

i ' s __~~~~..

i ^ ~~~~~~~~~~~~~~~~~~. ,

k'W&-- '_.5&:FIG. 8.-Case 5. A.W. Showing bronchiolar obliteration. (x 125.)

inspiratory and expiratory rhonchi and crepitationswere the main clinical features. The chest wasdeformed as a result of diffuse bronchial andbronchiolar obstruction and pulmonary emphysema.As the clinical pattern and physical signs were thoseof chronic or subacute bronchiolitis with recurrentexacerbations, it was no wonder that a diagnosis ofasthmatic bronchitis, or non-specific bronchiolitis,or fibrocystic disease of the pancreas wasmade.The course of the disease varied considerably.

In two patients it was steadily downhill, deathoccurring at the ages of 4i and 3 years. Bothpatients died of progressive respiratory failure, theresult of chronic infective bronchiolitis and pulmon-ary hypertension. One of the three living childrenis in good health, the only symptoms being a littlecough and breathlessness out of proportion to thedegree of physical activity. The other two areseverely limited, any active exertion resulting inbreathlessness. As these children have grownolder, infection has become less and their generalhealth correspondingly improved.The clinical features and bronchographic appear-

ances of Case 1 suggested that expansion andnarrowing of the bronchial walls with respirationwas due to considerable structural weakness. Lackof cartilage seemed to be the probable structuralweakness as similar expansion and collapse of thewalls of the trachea and main bronchi had beenobserved when cartilage was absent from mal-development (Ferguson and Neuhauser, 1944;Evans, 1949; and Holinger and Johnston, 1957).

The gross morbid anatomical findings in Case 5revealed dilatation of the sub-segmental bronchialdivisions which were soft to feel and easilycompressed, a marked contrast to the normalcontrols. Serial histological examination disclosedthat the cartilage was deficient or absent alongthe walls in most cases from the third divisiondown, but in small numbers was present in theangle of bifurcation of the bronchi. This deficiencyin cartilage in the bronchial walls readily explainsthe physiological defect observed under the x-rayscreen.The problem is whether this defect is a develop-

mental one, or whether it is secondary to infection.The available evidence favours a primary develop-mental origin for the following reasons. Thelesions were surprisingly uniform, involving almostthe entire bronchial tree from the second or thirdsegmental division downwards. The principaldefect in the structure of the bronchial wall was inthe amount and distribution of cartilage. Had thecartilage been destroyed by inflammation, otherstructures would almost certainly have been affected,e.g. muscle and elastic tissue, but there was littleevidence of this. Again, if inflammation hadcaused dissolution of cartilage in the walls of thebronchi, one would expect to find several bronchi inwhich no cartilage at all was present. In fact,however, in all cases where a division occurred onecould find a small piece of cartilage at the bifurca-tion, although the walls themselves remaineddeficient. Examination of the bronchograms showsa 'nipping in' at the site of branching of the bronchi,

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190 ARCHIVES OF DISEASE IN CHILDHOOD

corresponding presumably with this small piece ofcartilage.

In acquired bronchiectatic lesions cartilagedestruction rarely extends up to the first and secondsegmental divisions, and then never in a uniformmanner. Several patients examined in the presentgroup soon after the onset of the disease showedgross bronchographic changes. The duration andthe severity of the clinical infection was too shortand too mild to result in such gross structuralchanges in the bronchial walls or to destroy thecartilage and cause 'flapping' during respiration.In no single case of bronchiectasis due to acquireddisease have we seen changes comparable withthose in these patients. We therefore presume thatthe cartilaginous defect is a developmental one andthat the symptoms of chronic cough, wheezingfebrile episodes and later pulmonary emphysema,pulmonary hypertension and respiration failure intwo patients were consequent on chronic secondaryinfection in the bronchiolar tree.

SummaryFive children with an unusual type of generalized

bronchiectasis are described.The clinical features of chronic cough, wheezy

breathing and febrile attacks associated with wide-spread clinical signs in the chest and pulmonaryemphysema were easily confused with asthmaticbronchitis, or chronic non-specific bronchiolitis orfibrocystic disease of the pancreas.The clinical and radiological features in the five

patients and the morbid anatomical findings in onesuggest that the underlying basis is maldevelopmentin the cartilage of the bronchial tree.

REFERENCESEvans, W. A. (1949). Congenital obstructions of the respiratory

tract. I. Tracheal malformations. Amer. J. Roentgenol.,62, 167.

Ferguson. C. F. and Neuhauser, E. D. B. (1944). Congenitalabsence of the lung (agenesis) and other anomalies of the tracheo-bronchial tree. Amer. J. Roentgenol., 52, 459.

Holinger, P. H. and Johnston, K. C. (1957). Clinical aspects ofcongenital anomalies of the trachea and bronchi. Dis. Chest,31, 613.

APPENDIX

The lungs of five children of approximately the sameage as Case 5 were examined by macroscopic dissectionand by serial section of segmental bronchi and theirdivisions to establish a normal pattern for children ofthis age group (Gray (1954), Hayek (1953), Miller (1937)).The results are summarized below.

Macroscopic FindingsMethod. Fixed lungs were dissected with fine scissors

commencing at the segmental bronchus, which was calledthe first division bronchus (see Fig. 9). Any branchesarising from this were counted and the dissection wascarried as far as possible into the periphery of the lung.

Findings. The number of divisions of any segmentalbronchus depended on the distance between the origin ofthe bronchus and the lung tissue it supplied. It wasgreater in longer bronchi than in short, e.g. lingula, with10 macroscopically visible bronchial divisions, andpectoral, with five to six macroscopically visible bronchialdivisions.

Divisions were of two types. Larger bronchi arose ata very acute angle. Small bronchi generally arose at amuch greater angle from the parent trunk (lateralbronchi of Hayward and Reid, 1952).The concept of an axial bronchus (Hayward and Reid,

1952) was not always easy to demonstrate. Truedichotomous branching was common, the resultingbronchi being of similar calibre and coursing to the

periphery, each giving off approximately the samenumber of divisions (see Fig. 5b).

In general, however, a main or 'axial' bronchus couldbe followed from which lesser bronchi arose.The bronchi in the fixed state were firm and elastic.Circumferential cartilage plaques were present in all

segmental bronchi and distally for three to six divisions,depending on the length of the axial bronchus.

Isolated cartilage plaques occurred in the walls ofbronchi from the fourth to the tenth divisions, althoughthey were difficult to see in the more peripheral divisionsand their presence had to be confirmed by histologicalexamination.

Microscopic Findings

Serial sections were examined in continuity and all thebranches arising from an axial bronchus were countedand an accurate assessment made of their cartilagecontent. The findings confirmed those made macro-scopically.

Mucosa. Regular ciliated columnar epitheliumpseudostratified down as far as the smaller bronchioleswhen it tended to become simple columnar in type.Mucosa rested on a condensed layer of collagen andmerged with the underlying collagen network aroundmucous glands, muscle and cartilage.

Muscle. This occurred in regular fasciculi beneath themucosa and varied in thickness with the bronchi exam-



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G.FAFRA4Tf7PF RPnATJC"TFCTA.4S 101

2 Major bronchial divis-3 , s \ t ions. Large plates of

p/4 t cartilage each encir-cling --j of wall

7 6 Lesser bronchial divis-> '7 2 ions. Small plates of

848 | cartilage

Bronchioles (not re-presented) 10-12divisions

L. Post Basic Br.

FIG. 9.-Sketch of a typical normal bronchus and its divisions.Diagram shows method of numbering bronchi and distribution of

cartilage in them.

ined (from 50,u up to 500,u). Muscle composed only asmall portion of the thickness of the walls of the largerbronchi (I to -'0) and slightly more (1 to O) of themore distal divisions.

Cartilage. In the larger bronchi (in general divisions1-6) this was present as large plaques each partly en-circling the lumen (so-called circumferential cartilageplaques). Their thickness varied greatly, being greater

the larger the bronchus, and generally ranging from300-1,000,u (Fig. 6b).

In the lesser bronchi (axial divisions distal to thefourth or fifth, and most of the lateral bronchi) thecartilage was distributed sporadically in the wall asisolated bars joined by a condensation of collagen andelastic fibres. A cross-section of such a bronchus wouldreveal two to four small plaques around the circum-ference. Their thickness averaged 100-300,u. Suchcartilage plaques could be found distally as far as thesixth to tenth division, depending on which segment wasbeing examined.

Bronchioles. The transition from bronchus to bronch-iole was usually clear. Two criteria were used (a)cessation of cartilage, and (b) relation to surroundinglung. Thus, bronchi were always surrounded by acondensate of collagen in which ran several vessels,lymphatics and nerves, whereas bronchioles lay inintimate relation with lung parenchyma and lacked thiscollagenous mantle (Engel, 1947). In general the smallperipheral bronchi contained cartilage in their walls,but this was felt to be a less reliable criterion than thelatter.On these criteria bronchiolar divisions numbered

10-12 in most cases.REFERENCES

Engel, S. (1947). The Child's Lung. Arnold, London. Ch. 2. Thebronchial and bronchiolar distiibution and arrangement.Ch. 3. The developmental histology of the bronchial tree.Ch. 8. Bronchiectasis.

Gray, H. (1954). Gray's Anatomy. 31st ed. Ed. by T. B. Johnstonand J. Whillis. Longmans, Green and Co., London. Pp.1293-1299. The trachea and bronchi.

Hayek, H. Von (1953). Die menschliche Lunge. Springer, Berlin.In text.

Hayward, J. and Reid, L. M. (1952). The cartilage of the intra-pulmonary bronchi in normal lungs, in bronchiectasis and inmassive collapse. Thorax, 7, 98.

Miller, W. S. (1937). The Lung. Thomas, Springfield, Ill. Ch. 3.Intrapulmonary bronchi and bronchioli.



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