Seven cases with side effects of endoscopic Nd-YAG laser treatment in a total of 55 malignant cases with invasion to central airway were described. 1) Moderate bleeding was observed in 2 cases with thyroid cancer with tracheal invasion and lung adenocarcinoma. Pulsatory bleeding from the irradiated portion on tumor and tracheal tube was in an awake condition intubated urgently in the former, succeeded in hemostasis. Moderately continuous bleeding from the irradiated portion on tumor and intratumoral ethanol injection originated by us was very effective in the latter. 2) Tracheal wall perforations were observed in 3 lung carcinoma cases with tracheal invasion. Tracheal wall was partially perforated due to tumor necrosis caused by Linac radiotherapy treated following YAG laser in 2 of 3 cases and, perforation caused with tumor regression in one case, but mortal massive hemorrage from mediastinum in one case, indicating that one should consider tumor radiosensitivity when we dilate central airway by Nd-YAG laser endoscopically. Another tracheal perforation was occurred by the wrong direction of laser beam in a recurred case with tracheal strong deviation postoperatively. 3) Acute respiratory failure possibly induced from smoke inhalation was observed in 2 cases including esophageal and lung carcinomas, who had strong emphysema. This respiratory failure could be recovered by the management under mechanical ventilator, steroid and antibiotics administration. In conclusion, endoscopic Nd-YAG laser irradiation is considered to be a safe and effective procedure for malignant diseases invading the central airway, if sufficient preparations against rare but unignorable side effects Are established.

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The effects of the number of resected cartilages, omentopexy and immunosuppressive agents on the regeneration of mucosal epithelium at the anastomotic site was examined following tracheoplasty, bronchoplasty and lung allo transplantation in dogs. The reconstruction of the bronchial artery at the anastomotic site was also examined by postmortem microangiography. The tracheal anastomotic site was covered by epithelium and showed the vascular anastomosis 7 days after tracheoplasty. However, the greater the number of resected cartilages was acompanied by the greater delay in regeneration. At 2 weeks after bronchoplasty, the epithelium was regenerated and the reconstructed bronchial artery was patent anastomosis. Omentopexy was promoted the regeneration at the anastomosis. In lung allo transplantation, regeneration of bronchial mucosa and patency of the bronchial artery was revealed at 2 weeks after transplantation in dogs treated with Cyclosporine.

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Bronchoscopic and immunohistochemical findings of 43 lung cancers, histological types of which were defined through bronchial brushing and bronchial biopsy, were evaluated and compared. In the bronchoscopic findings, a primarily mucosal type was often found in squamous cell carcinoma while a primarily submucosal type was seen mainly in adenocarcinoma and small cell carcinoma. However primarily mucosal and submucosal types were mised in half of the squamous cell carcinoma cases, and some of adenocarcinoma originating from large bronchi were identified as primarily mucosal type. As for histochemical findings, although SC positive and keratin positive cases were generally observed in adenocarcinoma and squamous cell carcinoma, respectively, the stainability of keratin and SC was decreased in non-keratinized squamous cell carcinoma and poorly differentiated adenocarcinoma, respectively. These results indicated the multipotential of lung cancer in histological features, rather than the difficulty of histological diagnosis, because histological types of lung cancer could be estimated to a certain extent based on bronchoscopic and immunohistochemical findings, even though some were difficult to be diagnosed. Therefore, we should take all these considerations into account when deciding on a treatment regimen, including whether or not surgical treatment is indicated, and which drug is the best for chemotherapy.

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From 1984 to 1986, the transbronchial brushing cytology guided by the bronchofiberscope and the fluoroscope was carried out 203 times in 152 cases with the peripheral pulmonary lesions suspected malignancy. And 86 cases, 92.5% of 93 cases with peripheral lung cancer, were correctly diagnosed by the brushing cytology. We examined 65 cases which were negative in this brushing cytology. The chest X-ray films of 39 cases showed the nodular or tumorous shadow and the other 26 cases showed the infiltrative shadow. In the former, primary lung cancer was revealed in 5 cases; 2 bronchiolo-alveolar type adenocarcinoma, 1 mediastinal type adenocarcinoma, 1 small peripheral type squamous cell carcinoma (12mm in diameter) and 1 expansively growing large cell carcinoma. The tumor was so small, located so peripherally and so expansively growing that the cancer cells could not be obtained by the brushing. Especially, in the bronchiolo-alveolar type adenocarcinoma, the destruction of the lung tissue by the tumor was mere and some bronchi in the tumor were completely intact. Therefore, by the insufficient brushing for this tumor the cancer cells sometimes could not be desquamated from the tumor tissue. And, except of 1 case, all of the cases showed infiltrative shadow on the chest X-ray films were diagnosed as the inflammatory diseases. The only 1 case of malignancy was the small squamous cell carcinoma originated from the peripheral bronchus masked by the thickened pleura.

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Relationships between cell populations in the bronchoalveolar lavage fluids(BALF) and histological findings in the transbronchial lung biopsy(TBLB) specimens were studied in 26 nonsmokers and 14 smokers with untreated pulmonary sarcoidosis. The ratio of OKT4/OKT8 positive lymphocytes in the BALF was higher in nonsmokers without epithelioid cell granuloma in the TBLB specimens than in those with granuloma (p<0.01), and this was also recognized in nonsmokers without alveolitis in the TBLB specimens compared to those with alveolitis (p<0.05). In smokers the percentage of lymphocytes in the BALF was higher in patients with alveolitis in the TBLB specimens than in those without alveolitis (p<0.05), although this was not seen in nonsmokers. These results suggest that the percentage of lymphocytes in the BALF can guess the presence of alveolitis in the TBLB specimens in smokers with sarcoidosis.

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Oxycel-cotton-filling bronchial obstruction therapy through fiberoptic bronchoscope was performed in 6 cases of pneumothorax with continuing air leakage against tube drainage. Two cases (cases 1 and 6) were patients with giant bullae and one case (cases 4) was with pneumoconiosis. Two cases (cases 3 and cases 5) were iatrogenic pneumothoraxes with severe basal disease. Case 2 was treated 3 weeks after onset. Bronchial filling therapy was proved to be successful after 1-3 trials in 5 cases except case 6 and its complications were not detected. Bronchial filling therapy is an easy, safe and noninvasive procedure and requires no special devices. So, this procedure can be carried out in patient who cannot bear surgical treatment and is preferred as treatment of choice for the management of pneumothorax with continuing air leakage.

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The influence of examination by flexible fiberoptic bronchoscopy on respiratory function and gas exchange were observed in 33 cases of respiratory diseases. These cases were divided into three groups according to the type of examination procedure. Group A included 9 cases in which only observation, transbronchial lung biopsy or transbronchial brushing were performed. Group B included 15 cases in which bronchoalveolar lavage(BAL) was carried out using more than 50ml of physiological saline. Group C included 9 cases of bronchography(BG) using 15-30ml of radiological opaque contrast medium. The three groups were premedicated with atropine sulphate and local anesthesia with lidocaine before the fiberoptic bronchoscopy examination, and were measured the respiratory function and arterial blood gas values before and after the examination. No significant change in respiratory function was seen in group A. In spite of a reduction in VC, FEV1.0% and V25 were improved in group B. These findings might suggested a decrease in pulmonary compliance, due to washing out of the surfactant from the alveolar wall with physiological saline infusion and remaining BAL fluid in the alveolar space. In group C, VC and FEV1.0 were significantly decreased, and FEV1.0% and peak flow rate were also reduced. The latter findings might suggest air flow obstruction in the bronchial trees. PaO_2 was significantly reduced in all groups, especially groups B and C. There was no change in PaO_2. The changes of PaO_2 significantly correlated to changes in VC between before and after the procedure in group A and C. However, no correlation was found in group B. The changes of PaO_2 and FEV1.0 were significantly correlated in group C. The causes of hypoxemia during fiberoptic bronchoscopy in group B suggested a decrease in lung compliance and VA] Q ratio, and/or shunt effect in the respiratory zone of the lung due to saline infusion. On the other hand, in group C, hypoxemia might have occured not only because of decrease of VC but because of air flow obstruction due to remaining radiological opaque contrast medium in bronchial tree. It is necessary to monitor SaO_2 and/or supply oxygen during fiberoptic bronchoscopy, especially during BAL and BG procedure, to prevent hypoxemia.

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All of 7 cases of Wegener's granulomatosis experienced during the past 7 years had tracheobronchial Involvement. We investigated the clinical and bronchoscopic findings of these 7 cases. The most frequent finding in initial symptoms was nasal symptoms, and second was ear symptoms and fever. Respiratory symptoms were seen in all cases on clinical course. The elevation of ESR, CRP positive and RA test positive were seen frequently. All cases had lung disease, and infiltrative shadows on chest roentgenograms were seen in 6 cases and nodular or tumor shadows were in 4 cases. The tracheobronchial lesion were demonstrated focally or wide spread throughout the bronchial tract, from the subglottic space as far as the subsegmental bronchi. In the case examined in short duration from time of onset of symptoms or relapsed, redness, swelling, bleeding, engorgement of small vessels, irregularity, ulceration, thickening and elevated lesion, rarely polypoid lesion, were observed, while in the case treated, stenosis was seen bronchoscopically. Bronchoscopic examination should be performed to confirm the tracheobronchial lesions and to control the respiration in the patients with Wegener's granulomatosis.

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A 72-year-old female was admitted with dyspnea. Bronchoscopy revealed a tumor obstructing approximately 80% of the tracheal lumen, 3.0cm above the carina. The tumor was removed by circumferential resection of the trachea. The histology was benign mixed tumor, salivary gland type, arising from the tracheal wall. We reported the case of the tracheal benign mixed tumor and reviewed the Japanese literature.

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A 26-year-old female was admitted to our hospital because of fever, cough and yellow sputum. E.coli was cultured in sputum. Bronchoscopy revealed an anomalous bronchus located between the normal right and left main bronchi. The yellowish sputum came from the anomalous bronchus. The lesion was diagnosed as congenital bronchobiliary fistula by bronchography and 99mTc-HIDA hepatobiliary scintigram. The fistula extended from the carina to the left hepatic bile duct. Bronchography revealed the bronchiectasis of right middle and lower lobe. The resection of the fistula and right middle and lower lobectomies were performed. The recovery was uneventful. Congenital bronchobiliary fistula is very rare. Only 11 cases were reported in English language journals. All cases reported were less than three years of age. This may be the first case report seen in an adult.

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A 23-year-old male patient received positive pressure ventilation via orotracheal intubation for 8 days because of postoperative lung edema after left lung decortication. Approximately 3 weeks after extubation, dyspnea and stridor appeared with gradual worsening. Tomography revealed upper airway stenosis beginning 1.5cm below the vocal cord and extending for 3cm. The narrowest diameter was 3mm. Pressure necrosis due to intubation was considered to be the cause. On the 36th day after extubation, resection of the stenotic site was carried out, removing cricoid cartilage for 5mm and 3cm of the upper trachea. Direct crico-tracheal anastomosis using 3-0 Vicryl was performed. During the anastomosis, the oxygen jet insufflation(61/min) was employed safely. Supra-hyoidal laryngeal release and mobilization of the mediastinal trachea were added. Anterior flexion of the neck was maintained for 2 weeks. Oral intake was allowed on the 11th day. Slight swallowing disturbance was seen only during the first day. Healing of the anastomosis is excellent and vocal cord function is perfect 8 months after the operation.

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Complications after bronchoplastic procedures occur mostly at the anastomotic site, and necrotizing bronchitis of distal bronchus is rare. We describe a case of necrotizing bronchitis after left upper sleeve lobectomy. A 61-year-old case was diagnosed as squamous cell carcinoma of the lung by sputum cytology. The lesion was located in the left upper division bronchus on bronchoscopy. Left upper sleeve lobectomy was performed, necessitating wide bronchial dissection because of tight adhesion between the pulmonary artery and silicotic hilar lynph node. The stump of A^<1+2> was sutured by Prolene and this suture material was in contacted with the distal bronchial wall. However no bronchial wrapping was done. A thick white coat of pus was still found on the lateral wall of the distal bronchus one month postoperatively, but had disappeared on 4 months postoperatively. Wrapping of the anastomotic site should be performed to prevent this complication in case of extensive bronchial dissection.

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Bronchofiberscopy was employed to remove a foreign body (a cashew nut) in the bronchus of a 1 year 3 month old infant. A bronchofiberscopy, p10(Olympus Co., Ltd) was used with high-frequency jet ventilation. The foreign body was in the left upper lobe bronchus B^<1+2>. The bronchus was too narrow for the fiberscope to reach the upper division, and instead of a forceps to grasp the foreign body, a curette was used. The foreign body was raked out by the curette which was inserted into B^<1+2>. It is necessary to try a curette for removing a foreign body in places which are too narrow for forceps to function.

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A 55-year-old female suffered from severe tracheal stenosis and idiopathic thrombocytopenic purpura(ITP). She had been treated with glucocorticoids and high-dose immunoglobulin with a diagnosis of chronic ITP at another hospital. Since severe respiratory dysfunction caused by pneumonia that developed during treatment, she had been intubated using a cuffed tracheostomy tube for 47 days. About 2 months after extubation, she had progressively severe dyspnea because of tracheal stenosis and was referred to our hospital. After admission, endoscopic Nd-YAG laser therapy was carried out as an emergency treatment, but her dyspnea improved for only a few days. Before operation, 400mg/kg/day of intact immunoglobulin was administered for 5 days. After immediate and remarkable rise in the platelet counts, she underwent simultaneous tracheal resection and splenectomy. We consider that in emergency cases high-dose immunoglobulin therapy is useful for the management of patients with ITP. On the other hand for tracheal stenosis, in some cases, conservative therapy(dilatation, laser vaporization etc.) is the only treatment option, but tight or extensive strictures have responded best to surgical resection.

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Pulmonary involvement is common in primary amyloidosis, and infrequent in amyloidosis associated with chronic inflammatory states or with multiple myeloma. The etiology of primary amyloidosis is unknown. Pulmonary deposition of amyloid may be either diffuse or localized. Although chest roentgenographic abnormalities are present in 30-70% of patients with primary amyloidosis, the clinical course is generally dominated by symptoms of other organs. In a 68 year-old man complaining of dysphagia amyloidosis was diagnosed by biopsy of pharyngeal tumor. For further examinations, he was admitted to our hospital. Many diffuse nodular lesions were found in the larynx, trachea and bronchi. The surfaces of these nodular lesions were smooth and the color was almost normal. The biopsied specimens stained with H-E showed an eosinophilic amorphous material deposition under the mucous membrane. With Congo-red staining, the deposited material showed green birefringence by polarizing microscopy. This material resisted to KMnO_4 so it was suggested that it was A L amyloid. His chest X-ray and chest CT film showed posterior tracheal thickening but no lung parenchymal lesions. Further examinations revealed amyloid deposit in gastric erosions, thus this case was diagnosed as systemic primary amyloidosis. The incidence of diffuse tracheobronchial amyloid deposits in primary systemic amyloidosis is very low. Several cases have been reported in Japan.

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A 39-year-old male with chief complaints of nasal symptoms and slight fever was admitted to the Department of Otolaryngology. After 3 weeks he suffered from high fever, cough and hemoptysis and was transfered to our department. Fiberoptic bronchoscopy revealed marked erosions and granulomatous lesions in the lower trachea, bilateral main bronchi and the orifice of the right upper lobe bronchus. Biopsy of the orifice of the right upper lobe bronchus yielded a definitive diagnosis of Wegener's granulomatosis. He was treated successfully with 100mg/day of cyclophosphamide and 40mg/day of prednisolone and soon obtained. His endobronchial lesions also showed a marked improvement. We reviewed tracheobronchial lesions in 91 cases with Wegener's granulomatosis from 1980 in Japan. Thirtyone of 91 cases(34%) had an endobronchial lesion. Such an endobronchial lesion had been regarded as a rare manifestation of Wegener's granulomatosis. We would say that the incidence of such endobronchial lesions has showed a marked increase because of the longer survival of patients and of the more frequent application of fiberoptic bronchoscopy.

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A 63-year-old male patient with hemoptysis was admitted to our hospital for treatment of hemostasis. Prolonged bronchial bleeding from the right upper and middle lobe bronchi was halted by embolization of the right bronchial artery after unsuccessful conservative treatments involving endobronchial tamponade(the wedge method). The chest X-ray film showed a mild increase of linear markings and faint nodular opacities in both lungs. He had been working in polishing both the hard metal alloy blades of many kinds of saws and the hard metal cutting edges of tools, and had inspired the dust powder for 20 years. The hard metals mainly consisted of tungsten, cobalt and a few other elements. The lung tissues obtained by trans-bronchial lung biopsy showed marked infiltration of lymphoid cells and also mild fibrosis in the peribronchial regions and lung parenchyma. An electron microscopy elemental analysis of the lesion demonstrated the presence of most of the metals found in the powder but not of the cobalt. We found numerous particles of the hard metal dust from the polished particulates. Thesewere as small as a few micron and were inspirable as far as the bronchiols. Inspired cobalt was considered to have disappeared from the lesion since it is highly soluble. He responded well to corticosteroid therapy and his chest discomfort disappeared.

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