Netter Collection of Medical Illustrations: Respiratory System E-Book

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Respiratory System, 2nd Edition provides a concise and highly visual approach to the basic sciences and clinical pathology of this body system. This volume in The Netter Collection of Medical Illustrations (the CIBA "Green Books") has been expanded and revised by Dr. David Kaminsky to cover important topics like pulmonary hypertension, COPD, asthma, drug-resistant TB, modern endoscopic and surgical techniques, and more. Classic Netter art, updated illustrations, and modern imaging make this timeless work essential to your library.

  • Access rare illustrations in one convenient source from the only Netter work devoted specifically to the respiratory system.
  • Get a complete overview of the respiratory system through multidisciplinary coverage from physiology and biochemistry to adult and pediatric medicine and surgery.
  • Gain a quick understanding of complex topics from a concise text-atlas format that provides a context bridge between primary and specialized medicine.
  • Grasp the nuances of the pathophysiology of today’s major respiratory conditions—including pulmonary hypertension, COPD, asthma, environmental lung disease, sleep disorders, infections of the immunocompromised, neonatal breathing disorders, and drug-resistant TB, and modern endoscopic and surgical techniques—through advances in molecular biology and radiologic imaging.
  • Benefit from the expertise of the new editor, David Kaminsky, MD, who contributes significant experience in asthma and general pulmonary and critical care medicine, and his team of world class contributors.
  • Clearly see the connection between basic and clinical sciences with an integrated overview of normal structure and function as it relates to pathologic conditions.
  • Apply a visual approach—with the classic Netter art, updated illustrations, and modern imaging—to normal and abnormal body function and the clinical presentation of the patient.
  • Tap into the perspectives of an international advisory board for content that reflects the current global consensus.

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Published 04 February 2011
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EAN13 9781437736496
Language English
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The Netter Collection of
Medical Illustrations
Respiratory System
VOLUME 3
SECOND EDITION
A compilation of paintings prepared by
Frank H. Netter, MD
Edited by
David A. Kaminsky, MDAssociate Professor
Pulmonary and Critical Care Medicine
University of Vermont
Burlington, Vermont
Additional Illustrations by
Carlos A.G. Machado, MD
CONTRIBUTING ILLUSTRATORS
John A. Craig, MD
James A. Perkins, MS, MFA
Kristen Wienandt Marzejon, MS, MFA
Tiffany S. DaVanzo, MA, CMI
Anita Impagliazzo, MA, CMITable of Contents
Cover image
Title Page
Copyright
ABOUT THE SERIES
ABOUT THE EDITOR
PREFACE
ABOUT THE ARTIST FROM THE FIRST EDITION
INTRODUCTION TO THE FIRST EDITION
ADVISORY BOARD
CONTRIBUTORS
VOLUME 3
SECTION 1 ANATOMY AND EMBRYOLOGY
RESPIRATORY SYSTEM
BONY THORAX
RIB CHARACTERISTICS AND COSTOVERTEBRAL ARTICULATIONS
ANTERIOR THORACIC WALL
DORSAL ASPECT OF THE THORAX
INTERCOSTAL NERVES AND ARTERIES
DIAPHRAGM (VIEWED FROM ABOVE)
TOPOGRAPHY OF THE LUNGS (ANTERIOR VIEW)TOPOGRAPHY OF THE LUNGS (POSTERIOR VIEW)
MEDIAL SURFACE OF THE LUNGS
BRONCHOPULMONARY SEGMENTS
RELATIONSHIPS OF THE TRACHEA AND MAIN BRONCHI
BRONCHIAL ARTERIES
MEDIASTINUM
INNERVATION OF THE LUNGS AND TRACHEOBRONCHIAL TREE
STRUCTURE OF THE TRACHEA AND MAJOR BRONCHI
INTRAPULMONARY AIRWAYS
STRUCTURE OF BRONCHI AND BRONCHIOLES—LIGHT MICROSCOPY
ULTRASTRUCTURE OF THE TRACHEAL, BRONCHIAL, AND BRONCHIOLAR
EPITHELIUM
BRONCHIAL SUBMUCOSAL GLANDS
INTRAPULMONARY BLOOD CIRCULATION
FINE STRUCTURE OF ALVEOLAR CAPILLARY UNIT
LYMPHATIC DRAINAGE OF THE LUNGS AND PLEURA
PULMONARY IMMUNOLOGY: LYMPHOCYTES, MAST CELLS, EOSINOPHILS,
AND NEUTROPHILS
DEVELOPMENT OF THE LOWER RESPIRATORY SYSTEM
PHYSIOLOGY OF THE PERINATAL PULMONARY CIRCULATION
SECTION 2 PHYSIOLOGY
PULMONARY MECHANICS AND GAS EXCHANGE
RESPONSE TO OXIDANT INJURY
INACTIVATION OF CIRCULATING VASOACTIVE SUBSTANCES
ACTIVATION OF CIRCULATING PRECURSORS OF VASOACTIVE
SUBSTANCES
CONTROL AND DISORDERS OF RESPIRATION
SECTION 3 DIAGNOSTIC PROCEDURES
TESTS OF PULMONARY FUNCTION
RADIOLOGIC EXAMINATION OF THE LUNGSEXHALED BREATH ANALYSIS
FLEXIBLE BRONCHOSCOPY
BRONCHOSCOPIC VIEWS
NOMENCLATURE FOR PERIPHERAL BRONCHI
RIGID BRONCHOSCOPY
ENDOBRONCHIAL ULTRASONOGRAPHY
MEDIASTINOTOMY AND MEDIASTINOSCOPY
SECTION 4 DISEASES AND PATHOLOGY
CONGENITAL DEFORMITIES OF THE THORACIC CAGE
KYPHOSCOLIOSIS
CONGENITAL DIAPHRAGMATIC HERNIA
TRACHEOESOPHAGEAL FISTULAS AND TRACHEAL ANOMALIES
PULMONARY AGENESIS, APLASIA, AND HYPOPLASIA
CONGENITAL LUNG CYSTS
PULMONARY SEQUESTRATION
CONGENITAL LOBAR EMPHYSEMA
CHRONIC COUGH
COMMON LARYNGEAL LESIONS
LARYNGEAL AND TRACHEAL STENOSIS
VOCAL CORD DYSFUNCTION
BRONCHIAL ASTHMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
BRONCHIECTASIS
CYSTIC FIBROSIS
LUNG CANCER OVERVIEW
LUNG CANCER STAGING
SQUAMOUS CELL CARCINOMA OF THE LUNG
ADENOCARCINOMA OF THE LUNG
LARGE CELL CARCINOMAS OF THE LUNGSMALL CELL CARCINOMAS OF THE LUNG
SUPERIOR VENA CAVA SYNDROME
PANCOAST TUMOR AND SYNDROME
PARANEOPLASTIC MANIFESTATIONS OF LUNG CANCER
OTHER NEOPLASMS OF THE LUNG
BENIGN TUMORS OF THE LUNG
MALIGNANT PLEURAL MESOTHELIOMA
MEDIASTINAL TUMORS: ANTERIOR MEDIASTINUM
MIDDLE-POSTERIOR AND PARAVERTEBRAL MEDIASTINUM
PULMONARY METASTASES
OVERVIEW OF PNEUMONIA
PNEUMOCOCCAL PNEUMONIA
ATYPICAL PATHOGEN PNEUMONIA
STAPHYLOCOCCUS AUREUS PNEUMONIA
HAEMOPHILUS INFLUENZAE PNEUMONIA
GRAM–NEGATIVE BACTERIAL PNEUMONIA
VIRAL COMMUNITY-ACQUIRED PNEUMONIA
LUNG ABSCESS
OVERVIEW OF HEALTH CARE–ASSOCIATED PNEUMONIA,
HOSPITALACQUIRED PNEUMONIA, AND VENTILATOR-ASSOCIATED PNEUMONIA
PNEUMONIA IN THE COMPROMISED HOST
ACTINOMYCOSIS
NOCARDIOSIS
HISTOPLASMOSIS
COCCIDIOIDOMYCOSIS
BLASTOMYCOSIS
PARACOCCIDIOIDOMYCOSIS
CRYPTOCOCCOSIS
ASPERGILLOSIS
TUBERCULOSISNONTUBERCULOUS MYCOBACTERIAL LUNG DISEASE
OVERVIEW OF INHALATION DISEASES
SILICOSIS
COAL WORKER'S PNEUMOCONIOSIS
ASBESTOSIS AND ASBESTOS-RELATED DISEASES
BERYLLIUM
PNEUMOCONIOSIS CAUSED BY VARIOUS MINERALS AND MIXED DUSTS
HYPERSENSITIVITY PNEUMONITIS
PULMONARY EMBOLISM AND VENOUS THROMBOEMBOLISM
SPECIAL SITUATIONS AND EXTRAVASCULAR SOURCES OF PULMONARY
EMBOLI
PULMONARY HYPERTENSION
PULMONARY EDEMA
PATHOPHYSIOLOGY OF PLEURAL FLUID ACCUMULATION
PLEURAL EFFUSION IN HEART DISEASE
UNEXPANDABLE LUNG
PARAPNEUMONIC EFFUSION
PLEURAL EFFUSION IN MALIGNANCY
CHYLOTHORAX
RIB AND STERNAL FRACTURES
FLAIL CHEST AND PULMONARY CONTUSION
PNEUMOTHORAX
HEMOTHORAX
PULMONARY LACERATION
TRACHEOBRONCHIAL RUPTURE
TRAUMATIC ASPHYXIA
DIAPHRAGMATIC INJURIES
RESPIRATORY DISTRESS SYNDROME
ACUTE LUNG INJURY
IDIOPATHIC INTERSTITIAL PNEUMONIASCRYPTOGENIC ORGANIZING PNEUMONIA
PULMONARY ALVEOLAR PROTEINOSIS
IDIOPATHIC PULMONARY HEMOSIDEROSIS
LYMPHANGIOLEIOMYOMATOSIS
PULMONARY LANGERHANS CELL HISTIOCYTOSIS
SARCOIDOSIS
RHEUMATOID ARTHRITIS
SYSTEMIC SCLEROSIS (SCLERODERMA)
SYSTEMIC LUPUS ERYTHEMATOSUS
DERMATOMYOSITIS AND POLYMYOSITIS
PULMONARY VASCULITIS
EOSINOPHILIC PNEUMONIA
PULMONARY MANIFESTATIONS OF OTHER DISEASES
SLEEP MEDICINE
SLEEP-DISORDERED BREATHING
SECTION 5 THERAPIES AND THERAPEUTIC PROCEDURES
PULMONARY PHARMACOLOGY
PULMONARY REHABILITATION
OXYGEN THERAPY IN ACUTE RESPIRATORY FAILURE
METHODS OF OXYGEN ADMINISTRATION
OXYGEN THERAPY IN CHRONIC RESPIRATORY FAILURE (AMBULATORY
AND HOME USE)
INTRODUCTION OF CHEST DRAINAGE TUBES
CHEST-DRAINING METHODS
POSTURAL DRAINAGE AND BREATHING EXERCISES
UPPER AIRWAY OBSTRUCTION AND THE HEIMLICH MANEUVER
SECURING AN EMERGENT AIRWAY
ENDOTRACHEAL INTUBATION
TRACHEOSTOMYMORBIDITY OF ENDOTRACHEAL INTUBATION AND TRACHEOSTOMY
ENDOTRACHEAL SUCTION
MECHANICAL VENTILATION
TRACHEAL RESECTION AND ANASTOMOSIS
REMOVAL OF MEDIASTINAL TUMORS
SUBLOBAR RESECTION AND SURGICAL LUNG BIOPSY
LOBECTOMY
PNEUMONECTOMY
VIDEO-ASSISTED THORACOSCOPIC SURGERY
LUNG VOLUME REDUCTION SURGERY
LUNG TRANSPLANTATION
SELECTED REFERENCES
INDEXC o p y r i g h t
ELSEVIER SAUNDERS
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS: RESPIRATORY
SYSTEM, Volume 3, Second Edition
ISBN: 978-1-4377-0574-4
Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any
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Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
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mindful of their own safety and the safety of others, including parties for whom
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advised to check the most current information provided (i) on procedures featured
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or editors, assume any liability for any injury and/or damage to persons or
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2


ABOUT THE SERIES
Self-portrait: Dr. Frank Netter at work
The single-volume “blue book” that paved the way for the
multivolume Netter Collection of Medical Illustrations series,
affectionately known as the “green books.”
Dr. Frank H. Netter exempli ed the distinct vocations of doctor, artist, and teacher.
Even more importantly—he uni ed them. Netter's illustrations always began with
meticulous research into the forms of the body, a philosophy that steered his broad
and deep medical understanding. He often said: “Clari cation is the goal. No matter2



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how beautifully it is painted, a medical illustration has little value if it does not make
clear a medical point.” His greatest challenge and greatest success was chartering a
middle course between artistic clarity and instructional complexity. That success is
captured in this series, beginning in 1948, when the rst comprehensive collection of
Netter's work, a single volume, was published by CIBA Pharmaceuticals. It met with
such success that over the following 40 years the collection was expanded into an
8volume series—each devoted to a single body system.
In this second edition of the legendary series, we are delighted to o er Netter's
timeless work, now arranged and informed by modern text and radiologic imaging
contributed by eld-leading doctors and teachers from world-renowned medical
institutions, and supplemented with new illustrations created by artists working in
the Netter tradition. Inside the classic green covers, students and practitioners will
nd hundreds of original works of art– the human body in pictures– paired with the
latest in expert medical knowledge and innovation, and anchored in the sublime
style of Frank Netter.
Notable artist-physician, Carlos Machado, MD, the primary successor responsible
for continuing the Netter tradition, has particular appreciation for the “green book”
series, “The Reproductive System is of special signi cance for those who, like me
deeply admire Dr. Netter's work. In this volume, he masters the representation of
textures of di erent surfaces, which I like to call ‘the rhythm of the brush,’ since it is
the dimension, the direction of the strokes and the interval separating them that
create the illusion of given textures: organs have their external surfaces, the surfaces
of their cavities, and texture of their parenchymas realistically represented. It set the
style for the subsequent volumes of Netter's Collection - each an amazing
combination of painting masterpieces and precise scientific information.”
Though the science and teaching of medicine endures changes in terminology,
practice and discovery, some things remain the same. A patient is a patient. A
teacher is a teacher. And the pictures of Dr. Netter— he called them pictures, never
paintings—remain the same blend of beautiful and instructional resources that have
guided physicians' hands and nurtured their imaginations for over half a century.
The original series could not exist without the dedication of all those who edited,
authored, or in other ways contributed, nor, of course, without the excellence of Dr.
Netter. For this exciting second edition, we also owe our gratitude to the Authors,
Editors, Advisors, and Artists whose relentless e orts were instrumental in adapting
these timeless works into reliable references for today's clinicians in training and in
practice. From all of us with the Netter Publishing Team at Elsevier, we thank you.A brand new illustrated plate painted by Carlos Machado, MD,
for The Endocrine System, Volume 2, ed. 2Dr. Carlos Machado at workABOUT THE EDITOR
David A. Kaminsky, MD, is Associate Professor of Pulmonary and Critical Care
Medicine at the University of Vermont College of Medicine. He received his
undergraduate degree from Yale University, and medical degree from University of
Massachusetts Medical School. He completed his residency training in Internal
Medicine at Columbia Presbyterian Medical Center in New York City, and fellowship
training in Pulmonary and Critical Care Medicine at the University of Colorado
Health Sciences Center in Denver. He joined the faculty of the University of Vermont
College of Medicine in 1995 and continues to work as a clinician, researcher, and
educator. Dr. Kaminsky is the Clinical Director of the Pulmonary Function Lab,
Program Director for the Fellowship Training Program in Pulmonary and Critical
Care, and Associate Chair of the Institutional Review Board at University of
Vermont. His areas of research interest include pulmonary physiology, lung
mechanics, asthma, and COPD. His work has been funded by the National Institutes
of Health, the American Lung Association, the Whittaker Foundation, and other
agencies. Dr. Kaminsky has published nearly 40 original papers and a dozen book
chapters and reviews. He lives in the Burlington, Vermont, area with his wife andtwo children, two cats, and dog. He enjoys many outdoor activities, including
running, hiking, sailing, rowing, and ice hockey.
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P R E F A C E
It has been an honor to be the editor of the second edition— rst major revision in 30
years—of Netter's Respiratory System. The changes that have occurred over the past
3 decades in pulmonary medicine have been profound. The challenge of editing this
edition has therefore been to include these updates while at the same time preserving
the unique nature and artistic beauty of Netter's classic depiction of human health
and disease. In addition to ensuring the accuracy and relevance of the timeless topics
of anatomy and physiology, we have signi cantly revised the sections on airways,
parenchymal and pleural diseases, lung cancer, infectious diseases, thromboembolic
disease, inhalational diseases, acute respiratory distress syndrome,
pharmacotherapy, radiology, mechanical ventilation, and trauma and surgery. New
sections have been created on pulmonary immunology, pulmonary hypertension,
lung manifestations of systemic disease, sleep medicine, exhaled breath analysis,
endobronchial ultrasound, video-assisted thoracoscopic ultrasound, lung volume
reduction surgery, and lung transplantation. I am indebted to the many outstanding
contributors to this edition, who are each international experts in their eld. Without
their input, it would have been impossible to ensure that the most up-to-date,
accurate information would be provided to bring Netter's Respiratory Disease into
stthe 21 century. I would like to thank especially those contributors who have been
my teachers and mentors over the years: Drs. David Badesch, Jason Bates, Gerry
Davis, Barry Make, Ted Marcy, Polly Parsons, Charlie Irvin, Richard Irwin, Mike
Iseman, and Talmadge King. Special thanks also go to Dr. Je rey Klein, who made
extra e orts to provide radiographic images for many di erent sections of the book.
Finally, I want to dedicate this work to my grandfather, Dr. Edward Budnitz, who
shared with me his love of medicine and inspired me to pursue a career as a
physician.
David Kaminsky Burlington, Vermont
November 2010"
ABOUT THE ARTIST FROM
THE FIRST EDITION
The medical paintings of Dr. Frank Netter have received such wide acclaim from
physicians the world over for so long that the image of the man himself has begun to
take on mythical proportions. And, indeed, it is easy to understand how such a
transformation could take place. Yet, Dr. Netter is a real human being who breathes,
eats and carries on a daily routine just like the rest of us and who, for that matter,
stands a little in awe of the image which is so often ascribed to him.
In order to help a rm his reality as a man, we asked Dr. Netter to make the
accompanying self-portrait of himself at work in his studio. The sketch portrays a
number of elements which may be familiar to those who have seen photographs of
Dr. Netter's studio in previous volumes of THE CIBA COLLECTION OF MEDICAL
ILLUSTRATIONS or in other publications—the man himself, the drawing board, the
paints, the brushes, the skeleton and other accoutrements. The di0erence is in the
background. No longer is it the skyline of New York, which could be seen from his
former studio window. Now it is the open sunny landscape of southern Florida, with
waving palm trees and a boat traversing the waters of the intracoastal waterway.
Nevertheless, the Netters' move south from their long established New York home
does not signify an intention to wind down a highly productive work schedule.
Florida has meant a change in location and climate, but the intensity of Frank
Netter's commitment to what has become his life's work continues undiminished. Heis usually in his studio by 7:00 AM, where he concentrates on the project before him
until about two o'clock. The afternoons are mostly devoted to golf, to swimming in
the sea or pool, to 4shing, to time with his family or friends, or to other diversions.
At times he takes a “postman's holiday” to paint a landscape or a portrait just for the
fun of it.
But not all of Dr. Netter's work is done at the drawing board. Much of it consists of
intensive study and wide reading, observation of physicians at work in the clinic,
hospital or laboratory, and long hours of discussion with a collaborator. Even during
his hours of relaxation the concept of the illustrations is germinating in his mind.
After these preliminaries he makes pencil sketches, composing the details and layout
of the various elements of the illustrations, positioning x-rays and photomicrographs,
and determining the exact dimensions and placing of the legends in order to achieve
the maximum teaching e0ect. Only after the sketches are checked, double checked,
and revised for accuracy and detail does he proceed with the 4nished painting. Most
of his paintings are in water color, but at times he has used other media including
casein paint, chalks, acrylics or oils. He maintains, however, that the medium is not
very important. Good pictures can be made in any medium. He prefers water color
only because through long use he feels more at home with it and because he can
express himself more directly and work more rapidly with it.
Dr. Netter's great facility and skill at representative painting, gift though it may
be, did not come to fruition without dedicated study and training—not only in
drawing and painting but in graphic design, composition and layout as well. From
the time he was a little boy he wanted to be an artist. He studied intensively at the
National Academy of Design, the Art Students League of New York and other
outstanding schools as well as with private teachers. He won many honors and,
indeed, became a successful commercial artist in the heyday of that profession. But
then, partly because of his own interest and partly because of urging by his family to
do “something more serious” he decided to give up art and initiate a new career in
medicine. Once in medical school, however, he found that because of his graphic
training he could learn his subjects best by making drawings. So his early medical
illustrations were made for his own education. But it was not long before his
drawings caught the eyes of his professors, who then kept him busy in what little
spare time he had making illustrations for their books and articles. Netter graduated
from New York University School of Medicine and completed his internship and
surgical residency at Bellevue Hospital in the depths of the great depression. It soon
became evident that his art commissions from publishers and pharmaceutical
manufacturers were a better source of income than his depression-sti9ed medical
practice, and he made the decision to be a full-time medical artist.
Dr. Netter's association with the CIBA Pharmaceutical Company began in 1938with his creation of a folder cut out in the shape of a heart. Paintings of the anterior
and posterior (basal) surface of the heart were printed on the front and back and
sections of the internal anatomy were depicted on the inside. An advertising message
was overprinted both inside and out. The immediate response of physicians to this
piece was to request that it be produced without the advertising message. This was
done to great success, and thus was born a series of anatomy and pathology
illustration projects, the demand for which was so great that it eventually led, in
1948, to the publication of the 4rst book of TIBA COLLECTION OF MEDICAL
ILLUSTRATIONS. The year 1978, then, is not only the year of introduction of Volume
7, Respiratory System, but is also the thirtieth anniversary of the 4rst book of THE
CIBA COLLECTION OF MEDICAL ILLUSTRATIONS. COINCIDENTALLY, it is also the
thirtieth anniversary of the first issue of the CIBA CLINICAL SYMPOSIA series.
Dr. Netter is still preparing well over 100 paintings a year for The CIBA
COLLECTION OF MEDICAL ILLUSTRATIONS AND CLINICAL SYMPOSIA. Even now
he is well into the task of illustrating a new atlas on the musculoskeletal system.
Much has been said and written in the past about the Netter “genius.” Perhaps the
most impressive aspect of all is not his “genius,” but the use this remarkable
artistphysician-teacher makes of his gifts. His collective works are monumental, and they
continue to grow.
PHILIP B. FLAGLER#


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INTRODUCTION TO THE FIRST
EDITION
FRANK H. NETTER MD
Whenever a new atlas of mine appears, I feel as a woman must feel when she has
just had a baby. The tediousness and travail of the long pregnancy and the pain of
delivery are over, and it remains to be seen how my offspring will fare in the world.
In this case, there were a number of problems during the gestation. One of these
was that interest in the respiratory system and its diseases has not only greatly
increased in recent years but that its focus has been radically altered. The reasons for
these changes are manifold. They include the great di erences which have come
about in the incidence of various lung diseases; the advent and better utilization of
antibiotics; advances in radiologic technique and interpretation; the development of
additional diagnostic techniques such as radioactive isotope scanning; expansion in
the study of pulmonary physiology and application of pulmonary function tests;
progress in understanding of pulmonary pathology; increased facility in thoracic
surgery and the development of methods for predetermining operability, such as
mediastinoscopy; the design or improvement of technical and diagnostic mechanisms
such as oxygen and aerosol apparatus, mechanical ventilators, more e cient
spirometers and surgical staplers; and alterations in the personal habits,
environment and average age of the population.
All these factors, as well as others, are, however, interactive. For example, the
great decrease in incidence of pulmonary tuberculosis is related to the advent of
antibiotics: but it is also a consequence of improvement in living standards and
habits, as well as of improved early diagnosis. These factors may also be responsible
for the lesser incidence and morbidity of pneumococcal pneumonia. Whereas in
former years these two diseases were major concerns of the chest physician, they are
nowadays of much less signi cance. But this, on the other hand, has allowed more
time and e ort to be diverted to other lung disorders. The greatly increased
incidence of lung cancer appears to have resulted in considerable measure from
changes in personal habits (such as smoking), environmental pollution and
occupational activity, and possibly also change in population age. But earlier
discovery of tumors through greater public awareness and improved diagnosis, plus

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greater surgical facility, have led to increased interest in operability, and this in turn
has stimulated study of pathologic classi cation in relation to malignancy. The
increase in chronic bronchitis and emphysema, while largely real and attributable to
the same etiologic factors as cancer, may to some extent be only apparent—due to
better diagnostic methods and utilization of pulmonary function studies. But
recognition of some of the etiologic factors and better understanding of the
underlying pathologic processes, coupled with availability and utilization of such
measures as aerosol medication, improved equipment for oxygen administration and
mechanical ventilation, and postural drainage have greatly modi ed for the better
the management of these distressing disorders. The current relatively high incidence
of occupational diseases may likewise to some extent be only apparent, because of
greater awareness and better diagnosis. Pulmonary embolus and infarction have also
received increased attention in recent years as the common sources of emboli have
been identi ed, and as the manifestations of pulmonary vascular obstruction have
been more clearly defined.
In light of the foregoing examples of the changing emphasis in the eld of
pulmonary medicine, to which many more could be added, I have tried in this atlas
to give to each topic its proper emphasis in relation to the subject as a whole, in
accord with current concepts. In doing this, much consideration had to be given to
space availability. A good public speaker must deliver the essentials of his message
within the time allotted to him for if he rambles on and on, his audience is lost and
his message ine ective. So, too, the artist must portray his subject matter as
effectively as possible within the allotted pages. What to leave out becomes, at times,
as important as what to include. Without such considerations, this volume might
have grown to twice or three times its size and become unbalanced, or become so
crowded with minutiae as to be dull and boring. In either event, the utility of the
book would have been greatly impaired.
As in the preparation of all my previous atlases, my major e orts in this work
were again necessarily directed towards gathering, absorbing and digesting the
information about each subject so that I might properly portray it. Thus study,
learning and analysis of the subject matter became as time consuming, or more so,
than the actual painting of the pictures. One cannot intelligently portray a subject
unless one understands it. My goal was to picture or diagram the essence of each
subject, avoiding the incidental or inconsequential. In some instances I have,
however, included topics which, at present, do not seem to have great practical
application but which, in the future, may give important clues to pathogenesis,
diagnosis or treatment. All this was greatly facilitated, indeed made possible,
through the devoted cooperation of the many distinguished consultants who are
listed individually on other pages of this volume. I herewith express my appreciation
to each and every one of them for the time, e ort and guidance which they gave me,'

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and for the knowledge which they imparted to me. I also thank the many others
who, although not o cially consultants, nevertheless helped me with advice or
information or by supplying reference material to me. They are also credited
elsewhere in this book. I especially thank Dr. Matthew B. Divertie for his careful and
thorough review of both the pictorial and text material and for his many constructive
suggestions.
The production of this book involved a tremendous amount of organizational
work, such as assembling and compiling the material as it grew in volume,
correlating illustrations and text, grammatical checking, reference checking, type
speci cation, page layout, proofreading, and a multitude of mechanical and
practical details incidental to publication. I tremendously admire the e ciency with
which these matters were handled by Mr. Philip Flagler and his sta at CIBA,
including Ms. Gina Dingle, Ms. Barbara Bekiesz, Ms. Kristine Bean and Mr. Pierre
Lair. Finally, I once more give praise to the CIBA Pharmaceutical Company and its
executives for their vision in sponsoring this project and for the free hand they have
given me in executing it. I have tried to do justice to it.ADVISORY BOARD
Gillian Ainslie MBChB, MRCP, FRCP
Associate Professor and Acting Head
Respiratory Clinic, Groote Schuur Hospital
University of Cape Town Lung Institute
Cape Town, South Africa
Koichiro Asano MD
Division of Pulmonary
School of Medicine
Keio University
35 Shinanomachi
Shinjuku-ku, Tokyo, Japan
Eric D Bateman MBChB, MD, FRCP, DCH
Professor of Respiratory Medicine
Respiratory Clinic, Groote Schuur Hospital
University of Cape Town Lung Institute
Cape Town, South Africa
Dr. Santos Guzmán López
Jefe del Depto. de Anatomía
Universidad Autónoma de Nuevo León
Fac. de Medicina
Monterrey, Nuevo Leon, Mexico
John E. Heffner MD
William M. Garnjobst Chair of Medical Education
Pulmonary and Critical Care Medicine
Providence Portland Medical Center
Oregon Health and Sciences University
Portland, Oregon
Surinder K. Jindal MD, FCCP
Professor and Head, Department of Pulmonary Medicine
Postgraduate Institute of Medical Education and Research
Chandigarh, IndiaCONTRIBUTORS
Steven H. Abman MD
Professor
Department of Pediatrics, Section of Pulmonology
University of Colorado School of Medicine and The Children's Hospital
Aurora, Colorado
Plates 1-33 to 1-43
David B. Badesch MD
Professor of Medicine
Division of Pulmonary Sciences and Critical Care Medicine and Cardiology
Clinical Director, Pulmonary Hypertension Center
University of Colorado Denver
Aurora, Colorado
Plates 4-114 to 4-126
Peter J. Barnes DM, DSc, FRCP, FMedSci, FRS
Head of Respiratory Medicine
National Heart and Lung Institute
Imperial College
London, England, UK
Plates 2-22 to 2-24, 5-1 to 5-10
Jason H.T. Bates PhD, DSc
Professor of Medicine, Physiology, Biophysics
University of Vermont College of Medicine
Burlington, Vermont
Plates 2-14 to 2-21
Kevin K. Brown MD
Professor of Medicine
Vice Chairman, Department of Medicine
Director, Interstitial Lung Disease Program
National Jewish Medical and Research Center
Denver, Colorado
Plates 4-157 to 4-162
Vito Brusasco MDProfessor of Respiratory Medicine
University of Genoa
Genoa, Italy
Plates 2-8 to 2-13
Nancy A. Collop MD
Professor of Sleep Medicine and Neurology
Director, Emory Sleep Program
Emory University
Atlanta, Georgia
Plates 4-165 and 4-166
Bryan Corrin MD, FRCPath
Professor Emeritus of Pathology
London University
Honorary Senior Clinical Research Fellow
National Heart and Lung Institute
Imperial College
Honorary Consultant Pathologist
Royal Brompton Hospital
London, England, UK
Plates 1-1 to 1-16
Gerald S. Davis MD
Professor of Medicine
Pulmonary Disease and Critical Care Medicine
University of Vermont College of Medicine
Fletcher Allen Health Care
Burlington, Vermont
Plates 4-103 to 4-113
Malcolm M. DeCamp MD
Fowler-McCormick Professor of Surgery
Northwestern University Feinberg School of Medicine
Chief, Division of Thoracic Surgery
Northwestern Memorial Hospital
Chicago, Illinois
Plates 3-26, 5-25 to 5-33
Raed A. Dweik MD
Director, Pulmonary Vascular Program
Department of Pulmonary and Critical Care Medicine
Cleveland Clinic
Cleveland, OhioPlate 3-20
David Feller-Kopman MD
Director, Interventional Pulmonology
Associate Professor of Medicine
The Johns Hopkins Hospital
Baltimore, Maryland
Plates 3-21 to 3-25, 5-15 to 5-17, 5-20 to 5-23
Alex H. Gifford MD
Fellow, Pulmonary and Critical Care Medicine
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Plates 2-25 to 2-31
Curtis Green MD
Professor of Radiology and Cardiology
University of Vermont College of Medicine
Staff Radiologist
Fletcher Allen Health Care
Burlington, Vermont
Plates 3-4 to 3-19
Anne Greenough MD (Cantab), MB BS, DCH, FRCP, FRCPCH
Division of Asthma Allergy and Lung Biology, MRC, and Asthma
UK Centre in Allergic Mechanisms of Asthma
King's College London
Neonatal Centre
King's College Hospital
Denmark Hill
London, England, UK
Plates 4-1 to 4-9, 4-144, 4-145
Charles G. Irvin PhD
Vice Chairman for Research
Department of Medicine
Director, Vermont Lung Center
Professor, Departments of Medicine and Molecular Physiology & Biophysics
University of Vermont College of Medicine
Burlington, Vermont
Plates 2-1 to 2-7
Richard S. Irwin MD
Professor of Medicine
University of Massachusetts Medical SchoolChair, Critical Care
UMass Memorial Medical Center
Worcester, Massachusetts
Plate 4-10
Michael Iseman MD
Professor of Medicine
National Jewish Medical and Research Center
Denver, Colorado
Plates 4-93 to 4-102
James R. Jett MD
Professor of Medicine
National Jewish Medical and Research Center
Denver, Colorado
Plates 4-48 to 4-63
Marc A. Judson MD
Professor of Medicine
Division of Pulmonary and Critical Care Medicine
Medical University of South Carolina
Charleston, South Carolina
Plates 4-155 and 4-156
David A. Kaminsky MD
Associate Professor
Pulmonary and Critical Care Medicine
University of Vermont College of Medicine
Burlington, Vermont
Plates 3-1 to 3-3, 5-18
Greg King MB, ChB, PhD, FRACP
Head of Imaging Group
The Woolcock Institute of Medical Research
Department of Respiratory Medicine
Royal North Shore Hospital
St. Leonards, Australia
Plates 4-163 and 4-164
Talmadge E. King Jr., MD
Julius R. Krevans Distinguished Professorship in Internal Medicine
Chair, Department of Medicine
University of California, San Francisco
San Francisco, CaliforniaPlates 4-147 to 4-154
Jeffrey Klein MD
Director, Thoracic Radiology
Fletcher Allen Health Care
Professor
University of Vermont College of Medicine
Burlington, Vermont
Plates 3-4 to 3-19
Kevin O. Leslie MD
Professor of Pathology
Mayo Clinic Arizona
Scottsdale, Arizona
Plates 1-17 to 1-31
Donald A. Mahler MD
Professor of Medicine
Pulmonary and Critical Care Medicine
Dartmouth Medical School
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Plates 2-25 to 2-31
Barry Make MD
Professor of Medicine
National Jewish Medical and Research Center
Denver, Colorado
Plates 5-11 to 5-14
Theodore W. Marcy MD, MPH
Professor of Medicine
Pulmonary Disease and Critical Care Medicine Unit
University of Vermont College of Medicine
Burlington, Vermont
Plates 4-127, 4-128, 5-24
James G. Martin MD, DSc
Director, Meakins Christie Laboratories
Professor of Medicine
McGill University
Montreal, Quebec, Canada
Plate 1-32
Deborah H. McCollister RNUniversity of Colorado Health Sciences Center
Denver, Colorado
Plates 4-114 to 4-126
Meredith C. McCormack MD, MHS
Assistant Professor of Medicine
Division of Pulmonary and Critical Care Medicine
Johns Hopkins University
Baltimore, Maryland
Plates 4-28 to 4-42
Ernest Moore MD
Professor and Vice Chairman
Department of Surgery
University of Colorado Denver
Bruce M. Rockwell Distinguished Chair in Trauma
Chief of Surgery
Denver Health
Denver, Colorado
Plates 4-135 to 4-143
Michael S. Niederman MD
Chairman, Department of Medicine
Winthrop-University Hospital
Mineola, New York;
Professor of Medicine
Vice-Chairman, Department of Medicine
SUNY at Stony Brook
Stony Brook, New York
Plates 4-64 to 4-83
Paul M. O'Byrne MB, FRCPI, FRCPC
E.J. Moran Campbell Professor and Chair
Department of Medicine
McMaster University
Hamilton, Ontario, Canada
Plates 4-14 to 4-27
Polly E. Parsons MD
E. L. Amidon Professor of Medicine
Chair, Department of Medicine
Director, Pulmonary and Critical Care Medicine
University of Vermont College of Medicine
Medicine Health Care Service LeaderFletcher Allen Health Care
Burlington, Vermont
Plate 4-146
Elena Pollina MD
Department of Histopathology
King's College Hospital
London, England, UK
Plates 4-1 to 4-9
Catheryne J. Queen
Mycobacterial and Respiratory Diseases Division
National Jewish Health Medical and Research Center
Denver, Colorado
Plates 4-93 to 4-102
Michael P. Robich MD, MSPH
Department of Surgery
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
Plates 3-26, 5-25 to 5-33
Margaret Rosenfeld MD, MPH
Medical Director, Pulmonary Function Laboratory
Seattle Children's
Associate Professor of Pediatrics
University of Washington School of Medicine
Seattle, Washington
Plates 4-43 to 4-47
Steven Sahn MD
Professor of Medicine
Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine
Medical University of South Carolina
Charleston, South Carolina
Plates 4-129 to 4-134
Sanjay Sethi MD
Professor, Department of Medicine
Chief, Division of Pulmonary, Critical Care, and Sleep Medicine
University at Buffalo, SUNY
Section Chief, Division of Pulmonary, Critical Care and Sleep Medicine
Western New York VA HealthCare SystemBuffalo, New York
Plates 4-84 to 4-92
Damon A. Silverman MD
Assistant Professor of Otolaryngology
University of Vermont College of Medicine
Director, The Vermont Voice Center
Fletcher Allen Health Care
Burlington, Vermont
Plates 4-11 to 4-13, 5-19
Robert A. Wise MD
Professor of Medicine and Environmental Health Sciences
Division of Pulmonary and Critical Care Medicine
Johns Hopkins University
Johns Hopkins Asthma & Allergy Center
Baltimore, Maryland
Plates 4-28 to 4-42VOLUME 3
O U T L I N E
SECTION 1 ANATOMY AND EMBRYOLOGY
SECTION 2 PHYSIOLOGY
SECTION 3 DIAGNOSTIC PROCEDURES
SECTION 4 DISEASES AND PATHOLOGY
SECTION 5 THERAPIES AND THERAPEUTIC PROCEDURESS E C T I O N 1
ANATOMY AND EMBRYOLOGY
RESPIRATORY SYSTEM
The respiratory system is made up of the structures involved in the exchange of oxygen and carbon dioxide between the blood and the
atmosphere, so-called external respiration. The exchange of gases between the blood in the capillaries of the systemic circulation and the tissues
in which these capillaries are located is referred to as internal respiration.
The respiratory system consists of the external nose, internal nose, and paranasal sinuses; the pharynx, which is the common passage for
air and food; the larynx, where the voice is produced; and the trachea, bronchi, and lungs. Accessory structures necessary for the operation of
the respiratory system are the pleurae, diaphragm, thoracic wall, and muscles that raise and lower the ribs in inspiration and expiration. The
muscles of the anterolateral abdominal wall are also accessory to forceful expiration (their contraction forces the diaphragm upward by
pressing the contents of the abdominal cavity against it from below) and are used in “abdominal” respiration. Certain muscles of the neck can
elevate the ribs, thus enlarging the anteroposterior diameter of the thorax, and under some circumstances, the muscles attaching the arms to
the thoracic wall can also help change the capacity of the thorax.
In Plates 1-1 through 1-16, the anatomy of the respiratory system and signi( cant accessory structures is shown. It is important not only to
visualize these structures in isolation but also to become familiar with their blood supply, nerve supply, and relationships with both adjacent
structures and the surface of the body. One should keep in mind that these relationships are subject to the same degree of individual variation
that a, ects all anatomic structures. The illustrations depict the most common situations encountered. No attempt is made to describe all of the
many variations that occur.
PLATE 1-1PLATE 1-2PLATE 1-3PLATE 1-4PLATE 1-5PLATE 1-6PLATE 1-7PLATE 1-8PLATE 1-9
PLATE 1-10PLATE 1-11PLATE 1-12PLATE 1-13PLATE 1-14