We previously introduced a new method for estimating the airway compliance from the mouth-pressure curve obtained after abrupt interruption of airflow during forced expiration. Within about 100msec after the interruption of airflow at the mouth, the pressure curve suddenly increases (first step) and is followed by exponential rise (exponential phase) which reaches the alveolar pressure. Under iso-volume conditions, the exponential phase of the curve, which is effort independent, is determined by the pressure-volume characteristics of the downstream segment below the choke point.
Using this method, we measured the airway compliance of the downstream segment below the choke point in patients with tracheobronchopathia osteochondroplastica (TBO), tracheobronchomegaly (TBM), and chronic obstructive pulmonary disease (COPD).
According to the wave-speed theory, the maximum flow (V_max) during forced expiration is limited by the cross-sectional area and the airway collapsibility at the choke point. Fiberoptic bronchoscopy, which demonstrates the cross-sectional area and dynamic properties of the trachea during forced expiration, allowed us to validate our method, and evaluate the airway collapsibility.
The TBO patient was shown to have a very hard and narrow trachea by bronchoscopy; it hardly collapsed during cough or forced expiration. Her airway compliance was estimated to be zero at 60% forced vital capacity (FVC). This suggests that the downstream segment did not collapse at 60% FVC.
The trachea and main bronchi of the TBM patient collapsed very easily during forced expiration. In this patient the airway compliance value was 1.45ml/cm H₂O at 40% FVC, larger than that of normal subjects.
In patients with COPD (n=3), the compliance values were 2.0-2.5ml/cm H₂O at 50% FVC. These values were larger than those of normal subjects (1.00ml/cm H₂O at 50% FVC). This implies that the downstream segment of the airway is collapsible in COPD patients.
Considering the clinical, radiographic and endoscopic findings of the patients, we conclude that the values obtained by our method for measuring the airway compliance are reasonable. This method also provides the pressure-volume curve of the airway below the choke point. This curve is influenced by two factors: the location of the choke point and the collapsibility of the downstream airway segment. We think, therefore, that this method is very valuable in detecting functional disorders of the airway and lung. Unfortunately, however, the factors cannot be separated.

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In 19 patients with chronic respiratory disease, including 12 hypercapnic patients and 6 sleep apnea syndrome patients, blood gas analysis, hypoxic ventilatory response, and hypercapnic ventilatory response were examined before and after acetazolamide administration. In 8 patients who had marked disordered breathing during sleep, polysomnography was also conducted before and after acetazolamide administration.
A decrease in Pa_CO2 (52.8±2.3 SE → 43.4±1.8 Torr) and an increase in Pa_O2 (54.8±4.0 ← 67.7±2.5 Torr) were observed after acetazolamide administration in 9 hypercapnic patients, but in the other 3 hypercapnic patients no significant change was demonstrated. Mean inspiratory flow (V_T/T_I), inspiratory minute ventilation (V_I), hypoxic ventilatory response (ΔV_I/ΔSa_O2), and hypercapnic ventilatory response (ΔP.2/ΔP_CO2) were increased significantly with the administration of acetazolamide.
Acetazolamide induced an improvement of the apnea index (10.2±3.7 SE → 6.8±2.4), total apnea time (40±21 → 27±15min), and oxygen desaturation during NREM sleep.
Our study suggested that acetazolamide augments the ventilatory drive mainly due to metabolic acidosis, and this agent may be useful for correction of chronic carbon dioxide retention and disordered breathing during sleep.

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Recently the usefullness of thallium-201 myocardial imaging for the detection of right ventricular overloading is becoming widely accepted. To evaluate the correlation of (1) electrocardiogram and (2) arterial blood gas analysis with thallium myocardial imaging, we compared those findings in 21 patients with chronic lung disease. Visualization of the right ventricular free wall was observed in 10 cases but the extent of tracer activity was small.
1) We selected twelve electrocardiogram criteria for assessment of right ventricular overloading. Out of them, PII>0.2mV, QRSaxis>90, RV₅(V₆)<0.5mV, R/SV₅(V₆)<1.0, transitional QRS leftward≥V₅, V_1q R and predominant SI are specific for visualization of the right ventricular wall by tracer. Thallium activity ration (TAR) tended to decrease with increasing numbers of criteria satisfied.
2) The right ventricles of patients showing PAO₂ within 70 Torr or PaCO₂ more than 45 Torr were all visualized by tracer. Patients with visualization of the right ventricular wall showed significantly lower PaO₂ higher PaCO₂ and larger AaDO₂ than those without. Furthermore, TAR significantly correlated with PaO₂ and PaCO₂ (each r=0.68 and r=-0.71). The above results suggest that PaCO₂, as well as PaO₂, closely correlated with right ventricular overloading.

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We performed ultrasonically guided aspiration needle biopsy (UGNB) in 31 cases of mediastinal lesions and were able to confirm the pathological diagnosis in 22 cases (71%) without serious complications. By real-time imaging with a linear electronic array transducer, it was possible to obtain pathological information from mediastinal lesions safely and consistently, even in cases with lesions adjacent to the heart and major vessels.
On the other hand, it was difficult to differentiate these lesions by ultrasonographic imaging alone. Pathological diagnosis with UGAB was especially valuable in cases with lesions situated in the superior or anterior mediastinum.
It was concluded that this modality could be an extremely useful method for the diagnosis of mediastinal lesions.

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We described three cases of diffuse pulmonary hemorrhage (DPH) and evaluated the usefulness of bronchoalveolar lavage (BAL) in diagnosis of DPH.
Case 1, a 59-year-old woman, was a case of systemic lupus erythematosus with DPH and lupus glomerulonephritis. Case 2, a 65-year-old man, presented DPH and glomerulonephritis of unknown etiology, which was speculated to be caused by autoimmune disorders. Case 3, a 66-year-old man, also presented DPH and membranous glomerulonephropathy with depositions of IgG in granular pattern.
BAL was performed in these cases and disclosed elevated levels of erythrocytes and hemoglobin in the BAL fluid, compared with those from control patients (208×10³/mm³ for erythrocytes and 0.62g/dl for hemoglobin in case 1, 134×10³/mm³ and 0.40g/dl in case 2, 30×10³/mm³ and 0.20g/dl in case 3, while the average for control patients, 1.7±1.7×10³/mm³ and 0.026±0.019g/dl respectively). This difference was apparent in gross observation of BAL fluid. The presence of a high percentage of hemosiderin-laden macrophages in BAL fluid gave additional confirmation of the diagnosis of DPH.
In case 1, pulse therapy of methylprednisolone followed by oral administration of prednisolone and cyclophosphamide remarkably reduced DPH, until she died from CNS lupus six months later. In case 2, pulse therapy of methylprednisolone also improved DPH remarkably, but he died from DIC. However in case 3, pulse therapy of methylprednisolone and plasmapherasis failed to improve DPH, and he died shortly in spite of intensive care. We considered that early diagnosis of DPH following by administration of corticosteroid was very effective in improving the course of cases 1 and 2, and that BAL was very useful for the diagnosis of DPH.
BAL is a procedure which can be performed safely even at the bedside of patients with serious respiratory failure, so we think that BAL should be considered as the first examination of choice in the diagnosis of DPH, in which early diagnosis is often difficult.

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It is difficult to differentiate a tumor shadow from an atelectatic shadow by conventional X-ray examination. We therefore studied the utility of ultrasonography for tumor shadows associated with atelectasis.
In 17 of 18 cases, we could differentiate the tumor from the atelectasis with ultrasonography by paying attention to the level and homogeneity of internal echoes on real time scanning. In one case, a tumor in a homogeneous atelectasis shadow was too small to be detected with ultrasonography. In 15 of the 17 cases, the internal echo levels of the tumors were higher than those of atelectasis.
In following up tumor responses to chemotherapy and/or radiation therapy, ultrasonography could demonstrate the increase or decrease in tumor size as well as the appearance of cystic lesions caused by necrosis within the tumor. If the sonic window was not sufficient, however, the inner part of the shadow could not be assessed.
We conclude that it is important to evaluate tumor shadows associated with atelectasis by ultrasonography in addition to the conventional X-ray examination.

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Diffuse panbronchiolitis (DPB) is a chronic obstructive lung disease to which much attention has been paid because of its characteristic clinical features. Recently, it has been suggested that this disease is based on inherited predisposition. There have been some reports of sibling and parental cases. Our previous report of HLA analysis in A, B and C locus showed that the frequency of HLA-Bw 54 in patients with DPB was significantly higher (68.4%, relative risk; 16.8) than controls (11.4%). These data support them.
This report investigates the frequencies of HLA-DR antigens and the complement polymorphism.
1) In the analysis of HLA-DR antigens, there is no antigen which significantly increased in the patients with DPB. However, the number of patients who possessed DR1 or DR4 was elevated.
2) In the analysis of complement polymorphis, C4B*5 increased significantly compared to normal controls (p<0.05).
However result 2) stands to reason because in the patients with DPB, the frequency of Bw54 was elevated and Bw54 was linked closely C4B*5 as the extended haplotype, A24/11-C1-Bw54-C4·A3·B5-BFS-C2C-DR4. These data suggest that DPB is significantly associated with HLA-Bw54 or the haplotype including Bw54, and does not correlate with any specific HLA-DR antigens.

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A 63 year-old female came to our hospital with an abnormal shadow in the right lower lung field. Right lower lobectomy was performed under a diagnosis of lung cancer. Histological examination revealed that the tumor was adenocarcinoma, associated with non-caseating epithelioid cell granulomas both in the tumor and in the regional lymph nodes. The clinical course and laboratory data did not give any evidence of generalized sarcoidosis, and we concluded that it was sarcoid-like reaction in the primary tumor and the regional lymph nodes associated with lung cancer.

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A 52 year-old woman was admitted with complaints of fever, muscle weakness of the extremities and dysarthria. Chest roentgenogram showed a diffuse bilateral pneumonia shadow and severe hypoxemia was noted. A complication of myositis was highly suspected from clinical symptoms and an increased levels of CPK, aldolase and myoglobin in serum. DIC developed a few days after hospitalization. The patient had purchased a parakeet a month previous to admission and it died around the onset of the present illness. This history was suggestive of psittacosis. The psittacosis CF titer in serum increased from 1:16 to 1:32.
The patient was successfully treated with mechanical ventilation and administration of minocycline, corticosteroids and heparin, FOY.
Thereafter tuberculous pleuritis developed but treatment with RFP, INH and SM was successful.
Psittacosis should be considered as possibly affecting multi-organ systems and thorough care should be exercised in its management.

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