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Bronchopulmonary segment

A bronchopulmonary segment is a distinct anatomical and functional unit of the lung, defined as a portion of lung tissue supplied by a tertiary (segmental) bronchus and its accompanying pulmonary arterial branch, along with independent venous and lymphatic drainage, allowing it to function somewhat autonomously from adjacent segments.^[1]^[2] These segments are pyramidal in shape, with their apex directed toward the lung hilum and base toward the pleural surface, and are separated from one another by connective tissue septa, though they lack visible external markings on the lung surface.^[2]^[3] The right lung typically contains 10 bronchopulmonary segments distributed across its three lobes: three in the upper lobe (apical, posterior, anterior), two in the middle lobe (lateral and medial), and five in the lower lobe (superior, medial basal, anterior basal, lateral basal, posterior basal).^[3]^[1] In contrast, the left lung, which has only two lobes, usually features 8 to 10 segments: four to five in the upper lobe and lingula (apicoposterior, anterior, superior and inferior lingular), and four to five in the lower lobe (superior, anteromedial basal, lateral basal, posterior basal), with variations such as fusion of segments accounting for the range.^[2]^[1] This segmental organization arises from the branching pattern of the bronchial tree, beginning with the trachea dividing at the carina into main bronchi, then lobar bronchi, and finally the tertiary bronchi that define each segment.^[3] Bronchopulmonary segments hold significant clinical importance in radiology, pulmonology, and thoracic surgery, as they enable precise localization of pathologies such as infections, tumors, or atelectasis, and facilitate targeted procedures like segmentectomy, which removes a diseased segment while preserving healthy lung tissue.^[2]^[1] Their discrete vascular supply minimizes bleeding risks during resection and supports independent ventilation or collapse in conditions like bronchiectasis.^[2] Segmental anatomy also aids in standardized nomenclature for imaging and surgical planning, with international conventions established to name segments consistently across medical practice.^[3]

General Anatomy

Definition

A bronchopulmonary segment is a distinct functional unit within the lung's architecture, comprising a portion of the lung parenchyma supplied by a tertiary or segmental bronchus and its associated branches of the pulmonary artery and veins. This structure allows each segment to operate as a self-contained respiratory subunit, receiving dedicated airflow and blood supply for gas exchange.^[3]^[2]^[1] The segments are demarcated from one another by bands of connective tissue known as septa, which provide structural boundaries that support their independent ventilation and perfusion while enabling precise surgical isolation without compromising adjacent tissue. This separation enhances the lung's modularity, allowing localized responses to physiological demands or pathological changes.^[2]^[4] The concept of bronchopulmonary segments was first systematically described in the late 19th century by anatomist William Ewart in his 1889 monograph on bronchial and pulmonary vascular anatomy, laying the groundwork for understanding segmental organization. Further refinements occurred in the early 20th century through detailed dissections and bronchoscopic studies, with nomenclature and anatomical standardization achieved by an international ad hoc committee in 1949, which was subsequently adopted by the Thoracic Society and formalized in the 1955 Nomina Anatomica, significantly influencing post-World War II thoracic surgery.^[5]^[6]^[7] Functionally, these segments play a key role in ventilation-perfusion matching at the sub-lobar level, where the aligned bronchial, arterial, and venous supplies optimize the ratio of air to blood flow within each unit, thereby facilitating efficient oxygen uptake and carbon dioxide elimination across the lung.^[1]^[2]

Structural Features

Bronchopulmonary segments exhibit a characteristic macroscopic structure as discrete, pyramid-shaped units within the lung parenchyma. The apex of each segment points toward the pulmonary hilum, where the supplying segmental bronchus enters, while the base forms part of the pleural surface. This configuration facilitates efficient distribution of air and facilitates potential surgical isolation. The segments are delimited by intersegmental planes composed of loose connective tissue septa, which provide a natural boundary without forming rigid walls.^[3]^[8] These segments represent the primary subdivisions of the lung lobes, aligning with the lobar architecture of the lungs. In the right lung, which consists of three lobes, there are typically 10 bronchopulmonary segments, whereas the left lung, with two lobes, contains 8 to 10 segments depending on anatomical variations such as the fusion of certain subsegments. This organization ensures that each segment functions as an independent unit supplied by its own tertiary bronchus, contributing to the overall ventilatory efficiency of the organ. The size and volume of individual segments vary by location, lung side, and individual physiology, but they collectively account for the total lung capacity in adults.^[9]^[10] Microscopically, bronchopulmonary segments comprise a branching network of terminal and respiratory bronchioles that transition into alveolar ducts and sacs, culminating in clusters of alveoli responsible for gas exchange. The walls of these airways and alveolar septa are reinforced by elastic fibers, which allow for elastic recoil during expiration, and smooth muscle layers in the bronchioles that regulate airflow. Supporting structures include reticular fibers and capillaries embedded within the interstitium, but the segments lack cartilaginous support beyond the proximal bronchi and feature no impermeable barriers; instead, functional separation is maintained by the thin pulmonary interstitium and connective tissue septa. This tissue organization optimizes both structural integrity and respiratory function across the segment.^[11]^[8]

Vascular Supply

Each bronchopulmonary segment receives its arterial supply from a dedicated branch of the pulmonary artery, which arises through lobar and then segmental arteries that parallel the branching pattern of the bronchial tree. This arrangement ensures that deoxygenated blood from the right ventricle is distributed specifically to the parenchyma of each segment, supporting gas exchange within its confines. The pulmonary arteries bifurcate at the carina into right and left main trunks, with subsequent divisions corresponding to the 10 segments in the right lung and 8 to 10 in the left, maintaining anatomical and functional independence.^[12] Pulmonary venous drainage from each segment is handled by segmental veins that collect oxygenated blood and converge into the superior and inferior pulmonary veins on each side, ultimately emptying into the left atrium. Unlike the arteries, these veins course through intersegmental septa rather than strictly within segment boundaries, yet they exhibit minimal intersegmental anastomoses, which helps preserve the isolation of segments and limits collateral flow between them during pathological conditions. This configuration underscores the bronchopulmonary segment's role as a discrete unit for venous return.^[13]^[1] In addition to the primary pulmonary circulation, each segment benefits from a dual blood supply via systemic bronchial arteries originating from the descending thoracic aorta, which provide oxygenated blood primarily for the nutrition of airways, visceral pleura, and supporting structures rather than for gas exchange. These bronchial arteries, typically numbering three (two left and one right), form an anastomotic network with pulmonary arteries at the lobar and segmental levels but do not exhibit specific segmental branching patterns. This supplementary supply accounts for only about 1% of total lung blood flow and drains partly into pulmonary veins via precapillary anastomoses.^[8]^[12] Lymphatic drainage begins with intrasegmental vessels within the lung parenchyma of each bronchopulmonary segment, collecting interstitial fluid and directing it toward hilar lymph nodes for filtration and immune processing. These lymphatics are independent per segment, passing through intersegmental septa to reach the pulmonary hilum, where they connect to broader thoracic lymphatic pathways. This segment-specific drainage supports localized immune responses while minimizing cross-segmental spread.^[1]^[2] Overall, the vascular architecture of bronchopulmonary segments features rare intersegmental connections in both arterial and venous systems, reinforcing their functional autonomy and reducing the potential for collateral circulation in disease states.^[12]^[1]

Lung Segments

Right Lung

The right lung is divided into 10 bronchopulmonary segments, which are pyramidal subdivisions of the lung parenchyma, each supplied by a tertiary segmental bronchus and corresponding branches of the pulmonary artery and veins.^[8] These segments are grouped into three lobes: the superior lobe with three segments, the middle lobe with two segments, and the inferior lobe with five segments.^[3] The segments exhibit relative independence, allowing for targeted surgical resection while preserving surrounding lung tissue.^[9] In the superior lobe, the apical segment (B1) occupies the uppermost portion of the lung, directed superiorly toward the apex, and is supplied by the apical bronchus arising from the eparterial right upper lobar bronchus, which branches superior to the right pulmonary artery.^[14] The posterior segment (B2) lies posteriorly, extending along the back of the lobe in a wedge-shaped configuration, originating from the posterior bronchus of the upper lobar bronchus.^[3] Adjacent to it, the anterior segment (B3) is positioned anteriorly, forming a triangular area visible on the costal surface, and receives its bronchus from the anterior division of the upper lobar bronchus.^[8] The middle lobe contains two segments: the lateral segment (B4), which is the larger of the two and adopts a wedge-shaped form extending laterally toward the chest wall, supplied by the lateral bronchus from the right middle lobar bronchus; and the medial segment (B5), a smaller rectangular area directed medially adjacent to the heart, arising from the medial bronchus of the same lobar structure.^[3] These segments are separated by the horizontal fissure from the superior lobe and the oblique fissure from the inferior lobe.^[9] The inferior lobe features five segments, beginning with the superior segment (B6), which is positioned cup-shaped immediately above the major oblique fissure and may include medial and lateral subparts supplied by the superior bronchus branching early from the lower lobar bronchus.^[2] The basal segments include the medial basal segment (B7), located medially near the mediastinum; the anterior basal segment (B8), extending anteriorly along the diaphragm; the lateral basal segment (B9), positioned laterally on the costal surface; and the posterior basal segment (B10), directed posteriorly toward the paravertebral gutter, each arising from corresponding basal bronchi of the lower lobar bronchus.^[3] The segmental bronchi originate from the right main bronchus, which divides into the upper (eparterial) lobar bronchus for the superior lobe, the middle lobar bronchus for the middle lobe, and the lower lobar bronchus for the inferior lobe, with tertiary bronchi further subdividing to supply each segment.^[8] Anatomical variations occur occasionally, such as the fusion of the medial basal (B7) and anterior basal (B8) segments due to incomplete fissural development, which may alter the boundaries between them.^[15]

Left Lung

The left lung, unlike the right, possesses only two lobes—superior and inferior—due to the cardiac notch, resulting in typically eight to ten bronchopulmonary segments rather than ten, with the lingula serving as an anatomical equivalent to the right middle lobe.^[3] This asymmetry arises from embryonic development, where the left lung's segments may fuse, reducing the count.^[2] In the superior lobe, the apicoposterior segment (B1+2, per Boyden classification) occupies the upper half of the lobe and receives a shared bronchial trunk, while the anterior segment (B3) lies medially and anteriorly.^[1] The lingular segments, located anteriorly below the left main bronchus, consist of the superior lingular segment (B4) superiorly and the inferior lingular segment (B5) inferiorly, both contributing to the lingula's role in the upper lobe's anterior projection.^[1] The inferior lobe includes the superior segment (B6) at its apex, the anteromedial basal segment (B7+8 combined, fusing the anterior and medial basal parts due to the heart's proximity), the lateral basal segment (B9) on the side, and the posterior basal segment (B10) posteriorly.^[1] These segments are separated by connective tissue planes, facilitating potential isolated involvement in disease.^[3] The bronchial anatomy features a hyparterial left main bronchus that is longer (approximately 5 cm) and more horizontal than the right main bronchus, dividing into upper and lower lobar bronchi; the upper lobar bronchus then branches into the apicoposterior (B1+2) and anterior (B3) segmental bronchi.^[16] Variations in segment number (8, 9, or 10) occur due to fusions, such as in the lingular or basal regions, underscoring the left lung's total asymmetry with the right's consistent ten segments.^[17]

Clinical Relevance

Surgical Applications

Segmentectomy is a precise surgical procedure that involves the removal of one or more bronchopulmonary segments, targeting early-stage non-small cell lung cancer (NSCLC) while preserving surrounding healthy lung tissue to minimize postoperative respiratory compromise compared to lobectomy.^[18] This approach leverages the anatomical isolation of bronchopulmonary segments by connective tissue planes and independent vascular structures, allowing for targeted dissection along intersegmental planes using surgical staples, energy devices, or blunt dissection to divide segmental bronchi, arteries, and veins.^[19] The procedure can be performed via open thoracotomy or minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) or robotic-assisted surgery, which have enhanced precision and reduced recovery time since their adoption in the 1990s.^[20] The historical development of segmentectomy traces back to 1939, when Churchill and Belsey performed the first such operation to resect the lingular segment for bronchiectasis, highlighting the feasibility of segmental resection based on bronchopulmonary anatomy.^[21] Although initially applied to infectious diseases, its use for lung cancer was pioneered by Jensik in 1973, with refinements in the late 20th century enabling broader application through improved imaging and surgical tools.^[19] VATS segmentectomy, introduced in the 1990s, marked a significant advancement by reducing morbidity and promoting lung function preservation.^[18] Indications for segmentectomy primarily include peripheral tumors less than 2 cm in diameter, particularly those presenting as ground-glass opacities (GGOs) on computed tomography, in patients with stage IA NSCLC who may not tolerate lobectomy due to comorbidities or limited pulmonary reserve. As of 2024, guidelines from the National Comprehensive Cancer Network (NCCN) and the American College of Chest Physicians (CHEST) endorse segmentectomy as an alternative to lobectomy even for medically fit patients with small peripheral tumors.^[22]^[23] The JCOG0802/WJOG4607L randomized trial (published 2022) provided level 1 evidence, demonstrating superior overall survival with segmentectomy compared to lobectomy for small (≤2 cm) peripheral stage IA NSCLC, with 5-year overall survival rates of 94.3% versus 89.1%. Oncologic outcomes thus show at least comparable, and in select cases superior, efficacy to lobectomy when adequate resection margins (at least 2 cm) and lymph node sampling are achieved.^[24] Common complications include prolonged air leaks, occurring in approximately 6.5% of cases due to incomplete sealing of the intersegmental plane, and bleeding from inadequate vascular ligation during segmental artery division.^[19] Other risks encompass pneumonia, bronchopleural fistula, and, less frequently, empyema, though overall mortality remains low at 1-4% depending on patient fitness.^[20]

Pathological Considerations

Infectious diseases such as pneumonia and tuberculosis frequently localize within individual bronchopulmonary segments due to the anatomical constraints imposed by segmental bronchial pathways and surrounding connective tissue septa, which limit spread beyond the affected area.^[25] For instance, bacterial pneumonia often remains confined to a single segment following aspiration or inhalation, as pathogens are delivered via the segmental bronchus and contained by incomplete fissures or lymphatic drainage patterns.^[26] Tuberculosis, particularly reactivation forms, commonly affects the apical or posterior segments of the upper lobes or the superior segment of the lower lobes in approximately 95% of localized cases, attributed to higher oxygen tension and impaired local immunity in these regions.^[27] Neoplastic processes involving bronchopulmonary segments typically begin with segmental origins but can extend through lymphatic channels, disrupting the natural compartmentalization of the lung. Bronchogenic carcinomas, including non-small cell types, may arise within a specific segment but invade adjacent structures via peribronchial lymphatics, leading to multifocal involvement.^[28] Squamous cell carcinoma predominantly originates in central segments near the main or lobar bronchi, reflecting its association with chronic irritation from inhaled carcinogens in proximal airways.^[29] In contrast, adenocarcinoma tends to develop in peripheral segments, arising from distal alveolar or bronchiolar epithelium and often presenting as solitary or multifocal nodules confined initially to subpleural areas.^[28] Pulmonary abscesses form as contained collections of pus within a bronchopulmonary segment, often resulting from obstructed drainage in the segmental bronchus following necrosis from infection or aspiration. These abscesses are typically localized due to the pyramidal structure of the segment, which facilitates encapsulation by surrounding septa, though persistent blockage can lead to chronic suppuration if not addressed.^[30] Management often relies on targeting the affected segment's orientation for postural drainage, positioning the patient to promote gravity-assisted evacuation of purulent material from the specific segmental bronchus.^[31] Congenital anomalies affecting bronchopulmonary segments, such as sequestration or rare agenesis, predispose to recurrent infections by creating isolated, non-ventilated lung tissue vulnerable to bacterial colonization. Bronchopulmonary sequestration involves aberrant segmental lung tissue lacking normal bronchial communication, leading to frequent pulmonary infections, particularly in intralobar forms where shared pleura allows bacterial ingress from adjacent segments.^[32] Segmental agenesis, though exceedingly uncommon, manifests as absence of a bronchopulmonary unit, resulting in compensatory hypoplasia and repeated infectious episodes in the malformed region due to altered airflow dynamics.^[32] Epidemiologically, smoking-related lung diseases exhibit a disproportionate involvement of upper lobe segments, driven by the distribution of tobacco-induced carcinogens and chronic inflammation in well-ventilated apical regions. Lung cancers in smokers, including adenocarcinoma and squamous cell variants, show upper lobe predominance, with studies indicating up to 60% of cases localized to these segments compared to lower lobes.^[33] This pattern extends to smoking-associated interstitial diseases, where fibrosis and emphysema preferentially affect upper lobe bronchopulmonary segments, correlating with higher cumulative smoke exposure and impaired clearance mechanisms.^[34]

Imaging and Diagnosis

High-resolution multi-slice computed tomography (CT) angiography is a primary modality for delineating bronchopulmonary segments, providing detailed visualization of segmental bronchi and accompanying pulmonary vessels through contrast enhancement that highlights the segmental vascular supply.^[35] Three-dimensional (3D) reconstructions from these scans enable precise mapping of segmental anatomy, facilitating preoperative planning by simulating surgical resections and identifying anatomical variants.^[35] Fiberoptic bronchoscopy allows direct visualization of segmental bronchial orifices, enabling targeted interventions such as biopsy for tissue sampling or stent placement to relieve obstructions within specific segments.^[36] This endoscopic technique provides real-time assessment of airway patency and mucosal abnormalities at the segmental level, complementing radiographic imaging.^[36] Magnetic resonance imaging (MRI) offers functional evaluation of bronchopulmonary segments, particularly through contrast-enhanced perfusion sequences that detect defects in blood flow distribution across segments.^[37] Positron emission tomography (PET), often combined with CT (PET-CT), assesses metabolic activity in segmental regions, aiding in the staging of tumors confined to specific segments by quantifying glucose uptake.^[38] Since the 2010s, artificial intelligence (AI)-assisted tools have advanced CT analysis by automating the segmentation of bronchopulmonary segments, enabling rapid and accurate volume calculations for quantitative assessment of segmental involvement in diseases.^[39] Bedside ultrasound has emerged as a complementary technique for pleural assessment overlying lung segments, providing non-ionizing evaluation of effusions or consolidations in critical care settings.^[40] Diagnostic challenges in imaging bronchopulmonary segments include overlap of basal regions on conventional projections, which can obscure boundaries and necessitate multiplanar CT reconstructions for clarification.^[1] Additionally, serial CT imaging raises concerns regarding cumulative radiation dose, prompting the use of low-dose protocols or alternative modalities like MRI to minimize exposure while maintaining diagnostic efficacy.^[41]

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