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A 60-year-old man presented with a 4-day history of small volume haemoptysis. His medical history revealed a pericardiectomy with pericardial window creation for severe constrictive pericarditis secondary to seropositive rheumatoid arthritis in 1997 and pulmonary tuberculosis aged 7, with a treated recurrence in 2005. He was a lifelong smoker of 20 cigarettes per day. He lived independently. His regular medication included prednisolone 10 mg and meloxicam. On examination, he looked unwell. His heart rate was 140, respiratory rate 22 and oxygen saturations 96% on air. Auscultation revealed crepitations at the left lung base. He had 500 mL of brisk haemoptysis. His haemoglobin fell from 85 to 73 g/L. Inflammatory markers were raised (C reactive protein 169 mg/L, white cell count 14.7×109/L, neutrophil count 12.9×109/L), prothrombin time ratio was mildly raised (1.4), platelet count …

A 41-year-old woman attended hospital with a 2-week history of a post-prandial, left upper abdominal pain. The patient underwent upper gastrointestinal endoscopy, and multiple round oesophageal submucosal lesions (figure 1A) were observed. On ultrasound, these abnormalities were echoless and were identified as outside the oesophageal wall with blood flow detected by colour Doppler flow imaging. Moreover, one of the lesions was connected to the aorta (figure 1B). There were no other abnormalities reported by the patient in terms of medical history and, in particular, there was no history of genetic disease. The rest of the physical examination and laboratory tests did not reveal any clinical anomalies, although the patient reported a 10-day history of cough and dysphagia 2 months previously, at which time a chest CT scan showed no obvious cause. Figure 1 (A) Upper gastrointestinal endoscopy showing multiple round lesions …

A 48-year-old man was admitted to our hospital because of an abnormal lung shadow detected on health check-up. He had no history of lung disease. Chest X-ray showed a nodule overlapping the pulmonary artery at the right hilar area; there was no other abnormality (figure 1A). Contrast-enhanced CT of the chest showed hyperplasia of a right racemose haemangioma of a bronchial artery (RHBA), with an area of low density that was suspected as thrombus or malignant tumour (figures 1B, C). Bronchial arteriography showed a pattern that was similar to the beans of a pagoda tree (an herbal medicine) and revealed a blood flow that was disproportionally slow to the artery branch and was meandering in the right RHBA. In addition, there was a relatively small …

A young lifelong non-smoking patient presented to the emergency department after an episode of haemoptysis following a 2-month history of weight loss, cough and fever. He had a history of pulmonary tuberculosis during childhood, for which he completed 6 months of treatment. An initial non-contrast CT of the thorax revealed a right lower lobe opacity suggestive of necrotising pneumonia with an endobronchial lesion in the bronchus intermedius and associated mediastinal and hilar lymphadenopathy (figure 1). A subsequent CT angiogram revealed bilateral hypertrophic bronchial arteries and a 6 mm intrapulmonary pseudoaneurysm arising from the right bronchial artery (BA), forming …

It is increasingly recognised that the airway circulation plays an important role in airway diseases, either through a change in blood flow or through microvascular leakage. Most of the information available regarding the anatomy and physiology of bronchial blood flow and its regulation has necessarily derived from animal studies. However, there have recently been important advances in understanding airway blood flow in airway disease in humans through the development of non-invasive methods and in the quantification of microvascular leakage using plasma markers. These studies have shown that bronchial blood flow is increased in patients with asthma but not in those with chronic obstructive pulmonary disease, confirming previous pathology investigations. Changes in bronchial blood flow may in part reflect the generation of new vascular vessels, a process known as "angiogenesis" which is caused by airway inflammation. Angiogenesis and the resulting plasma leak affect airway physiology, drug clearance and its bioavailability. This review discusses the anatomy, physiology and regulation of bronchial blood flow in the normal and diseased lung, In addition, it analyses the effect of current medical treatment and discusses the potential use of new anti-angiogenesis medications. The development of non-invasive assessment of bronchial blood flow and the study of angiogenesis have provided a tool to investigate airway physiology in vivo; these advances will contribute to a better understanding of inflammatory airway diseases as well as the implication of these findings to management.

Three dimensional computer aided reconstructions of pulmonary vessels were used to investigate the distribution of vascular changes and the formation of collateral channels in 11 patients with congenital heart disease. In the patients with less severe grades of hypertensive pulmonary vascular disease obstructive changes were unevenly distributed, whereas in those with disease of grade 4 or more distribution became more even. Plexiform lesions occurred rather more frequently in supernumerary arteries arising laterally from a large parent vessel, whereas cellular or fibrous intimal thickening tended to affect dichotomous branches at the periphery. Hypertensive changes were confined to arteries of 100-150 microns diameter running along the necks of acini. Various types of collateral channels were found. In particular, the reconstructions suggest that pulmonary arterial blood at high pressure could flow into bronchial arteries via proximal bronchopulmonary arterial anastomoses, and thence by way of dilatation lesions to the alveolar capillaries.

A fit 59 year old man with no past medical history of respiratory diseases presented with chest pain and bilateral pleural effusions. On arrival at the specialist thoracic unit his haemoglobin was 7.2 g/l. A CT scan (fig 1) and selective arteriography (fig 2) confirmed …

A 33-year-old Caucasian male smoker presented to our rapid access lung cancer clinic with a single episode of moderate haemoptysis and no other respiratory or systemic symptoms. There was no relevant past medical history. As an adopted child he was unaware of any significant family history. The only finding on clinical examination was decreased air entry on the right side. Laboratory tests were all normal. Chest x-ray demonstrated a small right hemithorax with marked mediastinal displacement to the right, increased soft tissue opacity adjacent to the right side of the mediastinum causing widening of the right paratracheal stripe and loss of silhouette of the right heart border, and increased interstitial opacity throughout the right lung (figure 1A). A CT scan of the thorax confirmed the presence of a large amount of abnormal low attenuation soft tissue around the right side of the mediastinum, which also involved the azygo-oesophageal space causing considerable thickening of the oesophageal wall (figure …

El-Bermani, Al-Walid I. (1978). Thorax , 33 , 167-174. Pulmonary noradrenergic innervation of rat and monkey: a comparative study. The noradrenergic innervation of rat and monkey lungs was studied using the fluorescence histochemical method for norepinephrine of Falck (1962). In both species the noradrenergic nerves enter the lung at the hilum in association with the bronchial arteries. Major differences were noted in the distribution and pattern of these nerves, the most important of which are as follows: (1) Noradrenergic nerves have terminal varicosities in all divisions of the rat bronchial artery but are varicose in only the medium and small bronchial arteries of the monkey. (2) Noradrenergic terminals (varicosities) are in direct association with the bronchial smooth muscle in the monkey, but in the rat most of the noradrenergic nerves pass through the smooth muscle layer without forming terminal varicosities. Smooth muscle noradrenergic innervation is seen only at bifurcation points. (3) In the monkey pulmonary artery, noradrenergic terminals are restricted to the adventitio-medial junction while they appear in the media of the rat pulmonary artery. (4) Noradrenergic terminals are present in all pulmonary vein divisions of the monkey whereas in the rat the large pulmonary veins lack noradrenergic nerves. Both rat and monkey bronchial arteries and pulmonary veins were found to have adrenergic terminal varicosities deep in the medial layer. The rat pulmonary artery also has such medial terminations. In both species there is a preponderance of noradrenergic terminals in the vasa vasorum, and we think that this may be important in regulating the delivery of humoral substances to vascular walls.

Because pulmonary arteries are end arteries, the circulation within the lung once appeared to be simple. However, an increasing amount of information concerning the systemic contribution to this circulation, mainly through bronchopulmonary anastomoses, has made the picture complex. The intricate network that the bronchial vessels establish between the aorta and the pulmonary arteries on the one hand, and between the pulmonary veins and the caval system via the azygos veins on the other hand, is capable of expansion in various pathological states (Camarri and Marini, 1962). This work is an attempt to classify all the presently recognized situations into five circuits readily visualized and easily remembered. First, the anatomical connexions within the lung will be briefly reviewed; then I shall propose a model of the position these connexions hold in the framework of the whole circulation, and the four pathological aspects of this model. The bronchial arteries normally irrigate the bronchi down to the bronchioles but do not reach the alveoli, which are irrigated solely by the pulmonary vessels proper. Precapillary anastomoses are present between the two types of arterioles, as can be demonstrated in the human lung (Fig. 1), but they are not of functional importance in normal conditions. A second anastomotic pathway results from the absence of a limit between the bronchiolar and the alveolar capillary beds. A third connexion exists at the venous slope of both systems in the form of so-called broncho-pulmonary veins joining the venous bronchial plexus to the pulmonary veins. Towards the hilum this venous plexus forms true bronchial veins that drain into the azygos and caval systems. Thus there are three levels in the pulmonary vessels where systemic blood can enter: pre-, intraand post-capillary (Fig. 2; a, b, and c). Depending on that level, the systemic blood will

Histological details are given of bronchopulmonary anastomoses in a patient who died suddenly and was known to have sickle-cell anaemia.

Severe haemoptysis in a patient with cystic fibrosis was successfully treated on two occasions by bronchial artery embolisation.

L'arteriographie pulmonaire et bronchique permet au chirurgien de definir la resection la plus appropriee et la plus conservatrice. Associee aux methodes chirurgicales recentes comme les techniques d'agrafages, l'embolisation selective devrait assurer que la conservation maximale de tissu pulmonaire soit obtenue avec un minimum de difficultes chirurgicales