Asbestos Causes Most Damage by Being Apex

Asbestos Causes Most Damage by Being Apex.

*Corresponding authors:

Prof. Aaron R Casha, Faculty of Medicine & Surgery, University of Republic of malta Medical School, Mater Dei Infirmary, Msida MSD 2090, Malta.

Casha AR, Manché A, Gauci M, Navarro A, Farrugia E (2018) Common Pathophysiological Pathways for Upmost and Upper Lobe Lung Disease. J Infect Dis Epidemiol iv:053.

© 2018 Casha AR, et al. This is an open-admission commodity distributed nether the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


The lung is a heterogeneous organ due to the effect of gravity on the arterial supply and lymphatic organization, and this leads to a predilection of different pathologies to certain areas of the lung.

The pathophysiological factors that make the upper lobe “vulnerable” to various different pathologies are additive, and not mutually exclusive. They include a tall, thin body habitus with an antero-posteriorly flattened chest as associated with a low BMI, compounded by the poor apical blood supply and concomitant limited lymphatic drainage, possibly accentuated past a physically tall lung and a deep first rib furrow that makes the apex announced prominent.

These factors promote high physical stress with resultant tissue tearing or destruction caused by a negative circumferential stress vector inside the visceral pleura of the prominent apex, abetted past large-sized upmost alveoli resulting from the distortion of the lung under its own weight.

Adequate repair may be limited by the poor upmost blood supply, exacerbated by the presence of congenital apical bullae that are present in approximately 15% of an otherwise healthy population. The rubberband fibers inside the lung get damaged and replaced past scar tissue, aggravated past exposure to baneful particulates like cigarette smoke that overwhelm the power of the already meager apical antiprotease defence force to prevent elastic cobweb damage. Cycles of destruction, repair and healing lead to fibrobullous lesions and cavity formation in the postero-upmost expanse of the lung around the rib furrows; these and then turn into a scarred immunological enclave decumbent to further disease progression.


Pathophysiology, Lung, Apex, Tuberculosis, Biomechanics, Upper lobe-predominant disease


The lung is unlike many other organs in that it is not homogeneous in its structure or function but is heterogeneous with regards to its perfusion, ventilation and perfusion-ventilation ratios [1-iv], pleural force per unit area [v], lymphatic flow [6], mucociliary clearance [7,viii] and pleural mechanical stress [9]. Much of the heterogeneity of the lungs is due to the effects of gravity [x], its function as a pressure level vessel and of its shape as constrained by the thoracic wall [11,12].

These anatomical and physiological differences touch on the lung’south responses to various baneful factors that can be extrinsic or intrinsic. These include diverse environmental and congenital factors such as inhalation of injurious gases, particulates and antigens [xiii-sixteen], infections like tuberculosis (TB) and aspergillosis [17,18], and genetic disorders similar mutations in cystic fibrosis transmembrane conductance regulator (CFTR) protein and blastoff-one antitrypsin deficiency [xix,20].

The aim of this review is to show how diverse anatomical and physiological features of the upper lobes and apices of the lungs combine to the make this part of the lung more vulnerable to certain disease etiologies, (Table 1). In and then doing, nosotros aim to demonstrate a common pathophysiological pathway for apical and upper lobe lung illness.

Table ane: Nomenclature of upper lobe lung illness past predominant aetiological mechanism.
View Table 1

Anatomical and Physiological Factors

Rib furrows

The lungs occupy the pleural cavity. This cavity is not smooth internally simply characterized past ridges caused past the ribs. The most prominent rib ridge is that of the showtime rib. This may be such a deep furrow that a surgeon might feel a sharp edge on intra-operative palpation [21]; (Figure1). Computerized tomography scans in coronal and sagittal views show that the apex of the lung sticks out like a pollex from the rest of the lung; (Effigy 2). The result is that the apex geometrically has the shape like to that of a rugby ball or bullet, that is a prolate or elongated spheroidal shape.

Figure i: A,B) Anterior and posterior views of moulds of the lung apex showing prominent indentations in the lung parenchyma caused by rib furrows, specially that of the first rib which are deeper posteriorly. Modified after Stephenson [21].
View Figure 1

Figure 2: Inverted colorized coronal and sagittal reconstructions of a thoracic CT scan showing how the get-go rib indentation (pointer) causes the apex of the lung to exist very prominent, causing raised levels of pleural stress.
View Figure 2

Base to tiptop ratio of apex

Figure 3 shows the ratios of stress in spheres and in ellipsoids with varying ratios of major-to-minor (a/b) axes where S1
is the axial stress and S2
is the circumferential stress. When the ratio of the top to the base of the apex protruding beyond the outset rib reaches 1.42, the circumferential stress component becomes zero.

Figure three: Ratios of stress in spheres and in ellipsoids with varying ratios of major (a) to pocket-sized (b) axes showing axial stress Due southi
and circumferential stress S2. Modified later on Fryer [22].
View Figure 3

When the top to based ratio exceeds 1.42, the circumferential stress becomes negative and instead of containing the lung, it promotes an external traction force, that combined with the high negative pleural pressure level present at the apex of between -15 to -twenty cm HtwoO [5], causes an instability at the shoulder area of the prolate spheroid. This may result in tearing as the pressure vessel pulls apart. Thinning of the pleura with porosity may also occur [23]. The fierce or buckling result results in repair by scarring and fibrosis with repeated cycles of damage and repair that may promote crenel formation [11]. The negative curvature of the rib grooves farther aggravates the issue, resulting in the reversal of the normal surface loads (circumferential stresses), leading to vehement in the shoulder areas. The area almost at risk is the posterior aspect of the apex where the beginning rib furrow is virtually prominent.

Depression thoracic index

Thoracic index is defined as the ratio of anteroposterior and lateral breast diameters. In the fetus, chest cantankerous-department is circular, although fetal thoracic index exceeds unity in early on fetal evolution [24]. As children grow, the ribcage drops with gravity, resulting in a change from the horizontal ribs in the cone-shaped fetal chest with a thoracic alphabetize of 0.85 to a flattened rib cage with angulated ribs and a thoracic index of 0.6 by age 3 years.

Gravity acts on ribs to increment their bending of inclination with the horizontal, resulting in drooping of ribs with growth and crumbling, every bit the ribs pivot on their costo-vertebral joints. The initial driblet in rib angulation in children leads to a driblet in thoracic index every bit children start to walk upright [25]. The chest wall changes with age [26]; in detail, the thoracic index increases as the ribs driblet outwards and laterally with age. There is a progressive rounding of the thoracic muzzle with increasing historic period-related obesity [27], (Figure 4). Chest anteroposterior diameter increases but the lateral bore remains static [28]. Females have a smaller chest than males, with smaller anteroposterior and lateral rib cage diameters [28].

Figure 4: Changes in thoracic index ± 2 SE with age according to gender. Males take a lower thoracic alphabetize than females. SE is standard error for the sample mean and 2 SE the upper and lower 95% confidence limits (0.975 quantile of the normal distribution). Redrawn afterwards Takahashi [27].
View Figure four

The predilection for tuberculosis to bear upon the alpine, long-chested private supported Dock’s early on work in 1944 on the pathogenesis of TB [13,29]. Similarly, information technology has long been recognized [xxx] that typical spontaneous pneumothorax patients are alpine, thin males [31,32] with elongated lungs [33], a diminished anteroposterior diameter and a low thoracic index [34].

Body Mass Alphabetize (BMI)

Low BMI is strongly associated with a low thoracic alphabetize (AP flattened breast shape) [28]. 7 cohort studies on tuberculosis demonstrated a clear human relationship between BMI and incidence of TB across several countries and different levels of TB burden [35-42]. Though both poor nutrition and low BMI are associated with TB infection, they can be considered every bit independent factors [43], with depression BMI acting every bit a marker of low AP thoracic diameter.

Pulmonary vasculature

Low pulmonary pressure in the apex due to gravity has been proposed as a plausible explanation for apical lung disease since 1945 [44]. Although the blood flow in the apices is low, ventilation-perfusion (V/Q) ratios are loftier, so the fractional pressure of oxygen (pOii) in the apex is the highest anywhere in the lung at 132 mmHg which is ideal for the tubercle bacillus that is an obligatory aerobe [45,46]. At the uppermost parts of the lung, the pressure within the vessels may be less than the alveolar pressure, described as West zone 1 [47].

Withal, bear witness at present indicates that gravity has a less important role in the pattern of regional distribution of ventilation and claret menses in the lung compared to structural features of the airways and blood vessels [48]. The gravitational model cannot explain lack of postural inequality in the prone position and heterogeneity of ventilation and perfusion distribution at the aforementioned vertical level with persistent heterogeneity in the absence of gravity [49]. The non-symmetrical fractal branching of the bronchial and pulmonary vascular beefcake is now considered to be the about important factor causing heterogeneity of perfusion and ventilation in the lungs [fifty].

Both the gravitational and fractal models outcome in a relatively over-ventilated noon (V/Q ratio 3:1) and an over-perfused base (V/Q ratio 0.half dozen:i) [one]. The balance between repair, protection by antiproteases and destruction by exposure to cigarette smoke may be altered by the relative hypocapnic alkalosis in the apex. In a rabbit lung model, hypocapnic alkalosis was directly injurious to the lung and potentiated ischemia-reperfusion-induced astute lung injury [51]. The commitment of deleterious gases is also higher in the apex, potentiating the problem. This pathophysiological machinery is too relevant to diseases like smoking, centrilobular emphysema and cadmium exposure, where the elastic fibers are weakened by antiproteases [fifteen,52,53]. Furthermore, local apical respiratory alkalosis may explain the upper lobe location of metastatic pulmonary calcification secondary to renal failure, secondary hyperparathyroidism, intravenous calcium therapy and osteolysis due to metastases or multiple myeloma due to a subtract in calcium solubility in alkaline tissue [13].

Lymphatic system and particle clearance

From the low apical pulmonary arterial pressure model follows the greatly diminished regional formation of tissue fluid or lymph. Dock’s lymph stasis theory provides an explanation for the apical localization of pulmonary TB [44], chronic pulmonary histoplasmosis and certain inorganic dust diseases [17]. Yet, the lymph stasis theory fails to explicate TB in the apex of the upper lobe [54,55], which the pressure vessel model (encounter below) can business relationship for [12].

The lymphatic arrangement plays a crucial role in particle clearance. The size of the particle load is important since a large load overwhelms the alveolar macrophage [56-58]. In the literature, particle size ranges are oft classified every bit coarse (> 2.v microns in diameter), fine (< 2.5 μm) and ultrafine (0.001-0.1 μm) [59]. The increased pulmonary toxicity of ultrafine particles is related not only to the large surface surface area in relation to their mass simply too to their interstitial access every bit they bypass the mucociliary escalator [60].

Particles greater than five-x μm are unlikely to reach distal airways, whereas particles smaller than 0.5 μm move into and out of alveoli by improvidence, oftentimes without substantial deposition and injury. Particles between 1-5 μm diameter get lodged at the bifurcation of the distal airways [61,62] near the juxta-alveolar origin of the lymphatic channels, making them more dangerous [63]. At the alveolar duct bifurcations, macrophages accumulate and engulf trapped particulates.

have a diameter of between 1-100 nanometers (nm) and tin can translocate easily from lung epithelium to regional lymph nodes, to the blood circulation and then accumulate in diverse organs of the body. There is notwithstanding simple cognition nigh the curt- and long- term effects of nanoparticles delivered to the lungs, but some are toxic at the cellular biochemical level [64,65].

Clearance of particles by lymphatics is slow [66] and in the apex is express by diminished arterial driving force per unit area and past the decreased apico-posterior chest wall move, which lessens the effectiveness of the chest wall movement acting every bit a respiratory pump [67]. Pathophysiologically, decreased lymphatic clearance occurs in chronic granulomatous illness (tuberculosis, sarcoidosis [68], eosinophilic granuloma [69], bronchocentric granulomatosis [lxx], chronic histoplasmosis [17] and farmer’due south lung [71]) and pneumoconiosis [13]. Whilst coal grit is relatively inert, silica, asbestos and beryllium are more reactive and cause fibrotic reactions at lower concentrations [72]. Reactive particles trigger the macrophages to initiate an inflammatory response and promote fibroblast proliferation and collagen deposition, leading to predominantly upper lobe fibrosis particularly posteriorly.

Mechanical Factors

Pressure vessel model

Modelling the thorax every bit a pressure vessel, apical pleural stress is x-fold that of the lung base of operations. In an antero-posteriorly flattened chest there is a further fou-fold increment; when combined this results in a twoscore-fold increment in pleural stress [x,12,73,74]. A tall, unsupported apex is therefore decumbent to increased stress leading to apical TB and spontaneous pneumothorax; this geometrical shape may likewise explain the occurrence of both TB and pneumothorax in the apex of the lower lobe where ventilation-perfusion ratios and blood menstruation are optimal, lymphatic clearance is normal and ventilation is average [54,55]. It likewise explains the pathophysiology of post lobectomy air leak, where air leak is more in the upper lobes and also on the right compared to the left due to the loss of chest wall conformational support leading to high pleural stress [75].

Apical alveolar size

The pressure vessel model above differs from that described past West which considered gravity distorting the lung under its own weight, leading to a higher strain in the apices and a fourfold increment in apical alveolar size [76]. With a fixed rib cage such as in ankylosing spondylitis, apical stress was higher [77] and lymphatic clearance diminished due to decreased pulmonary pump action [67], leading to fibrosis and cavitation in the upper lobe [78-80].

Elastic fibers

The lung is elastic and its elastic recoil is balanced past the tendency of the chest wall to spring outwards. The elastic fibers are weakened by exposure to cigarette smoke, which is a pregnant source of cadmium exposure [81].

Marfan’south syndrome is a genetic disorder affecting fibrillin, a glycoprotein essential for germination of elastic fibers in connective tissue [82]. This can commonly outcome in pneumothorax [83,84] and rarely cystic changes, emphysema, pneumonia, bronchiectasis, bullae and upmost fibrosis [85]. The mechanism is due to repeated cycles of healing of disrupted, highly stressed upmost interstitial tissue.

Centrilobular emphysema, the commonest blazon of pulmonary emphysema, is a routinely found in asymptomatic elderly patients. It is predominantly located in a patchy distribution in the upper zones of each lobe, that is the apical and posterior segments of the upper lobe and the superior segment of the lower lobe [86] and appears every bit emphysematous spaces of up to one cm diameter, located centrally within the secondary pulmonary lobule, replacing the central bronchovascular parcel [86,87]. It is strongly associated with smoking in a dose-dependent manner [88].

Normal blastoff-one antitrypsin is an antiprotease that protects confronting neutrophil elastase that would otherwise harm elastic fibers. Patients with blastoff-one antitrypsin deficiency develop upper lobe emphysema exacerbated by exposure to cigarette smoke and ecology dust; still, emphysema may develop at an early historic period even without significant smoking [20].

In contrast, in cystic fibrosis the cystic fibrosis transmembrane conductance regulator (CFTR) protein responsible for efflux of chloride and inhibition of sodium channel activeness is not-functional, resulting in ordinarily sparse fungus secretions becoming thick and inspissated, thus preventing adequate particle clearance and leading to bronchiectasis of the upper lobes and upmost segment of lower lobes [89].

Patients with pleuropulmonary fibroelastosis (PPFE) show clinically progressive refractory upper lobe fibrosis, with clinical information suggesting a link to recurrent pulmonary infection [ninety]. These patients are slender, with a flat rib cage and narrow anterior-posterior diameter [91].


The lung is a heterogeneous organ with respect to V/Q ratio, lymphatic flow and mechanical factors; these are summarized in Effigy five. Although some factors are related to gravity others are consequent on the chest wall and pleural crenel shape [12]. These differences dictate how the lung responds to extrinsic inhaled stimuli and intrinsic mechanical characteristics. In the normal upright lung, most blood flow and ventilation occurs in the lower lobes [47], yet despite an expectation that most inhaled pathogens or noxious gases would therefore be delivered to the dependent portion of the lung, the reverse often happens, with the upper one third of the lung comprising the upper lobe and upper segment of the lower lobes oftentimes involved in pathology [13]. In contrast, where the injurious factor is delivered solely through via the bloodstream, such as with drugs (amiodarone, nitrofurantoin, methotrexate and illicit drugs), the illness predominantly affects the basal part of the lung.

Effigy 5: Regional differences in the normal lung, showing apical and basal values for ventilation, ventilation-perfusion ratios (5/Q), perfusion, pulmonary artery (PA) force per unit area, lymph flow, hydrogen concentration equally pH, partial pressure of oxygen, pleural stress and alveolar size. Based on Casha [9], West [47] and Gurney [xiii].
View Figure 5

The upper lung suffers a greater concentration of particulates and pathogens that tin overwhelm its meager antiprotease defenses [92] limited by poor blood period, lymphatic stasis that fail to clear the offending pathogen or particulates and increased mechanical stress (force per unit area vessel model). This may limit healing and promote scarring, subpleural bleb formation and maybe cavitation [nine,11,12]. The increased mechanical stress leads to repair past fibrosis and scarring with the germination of apical vascular adhesions due to relative depression blood supply in the noon. At increased adventure is the 15% of the population who are built-in with congenital upmost blebs who are at high chance of disease progression should their body habitus be alpine, thin with an antero-posteriorly flattened breast typical of a depression BMI build [93].

The various factors we accept described all contribute to a common pathophysiological pathway. Ofttimes in upper lobe pulmonary affliction, the patients are described every bit tall and sparse with depression BMI [thirteen,42,43]. In a comparative report betwixt colliery workers beyond the Uk, there was a statistical difference in BMI between those who suffered from pneumoconiosis (tall, light men) and healthy co-worker (brusk, heavy men) controls matched for geographical colliery location, pit purity and level of dust exposure [94].

These pathophysiological factors do non exclude disease in the lower lobe. Just a pocket-size modify in the balance between repair and injury is required to alter the event. For example, the radiological pattern of reactivation of TB, which classically occurs in the postero-apical office of the upper lobe, changes to lower lobe consolidation when there is immunosuppression with HIV [95]. In asbestosis, the size and needle like shape of the asbestos fiber (length 100 μm, bore 30 μm) favors entrapment in the lower lobes [96-98].


The pathophysiological factors that make the upper lobe “vulnerable” to sure pathologies are additive, and not mutually exclusive. They include a tall, thin body habitus with an antero-posteriorly flattened chest, typically associated with a low BMI, and a poor upmost claret supply and concomitant poor lymphatic drainage perhaps accentuated by a alpine lung, with prominent offset rib furrow that makes the apex appear prominent. These factors either promote physical stress with its consistent tissue vehement or devastation caused by a negative circumferential stress vector inside in the visceral pleura in a prominent apex or preclude acceptable healing due to a poor claret supply, abetted perhaps by the presence of congenital upmost bullae nowadays in approximately fifteen% of an otherwise healthy population. The elastic fibers within the lung become damaged and replaced by scar tissue, aggravated by exposure to noxious particulates like cigarette smoke that overwhelm the power of the already meager antiprotease defenses to prevent harm of the elastic fibers. Cycles of destruction, repair and healing lead to cavity formation in the postero-apical expanse of the lung around the rib furrows; these then increasingly become a scarred immunological enclave prone to further disease progression.


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Asbestos Causes Most Damage by Being Apex