The bronchofiberscopic findings of 12 airway burn cases were presented and discussed. Airway burns were classified according to the couse. Inhalation burn : due to heated particles or mucosal-stimulating-chemical-agents are inhaled. Flash burn : due to an explosion. Mixed type : involves both inhalation burn and flash burn. Extensive airway burn occurs more easily in inhalation burn rather than in flash burn or mixed type. Bronchofiberscopic findings were classified into 4 types ; secretions only, sooty only, redness and swelling of the bronchial wall, bronchial wall necrosis. In both flash burn and mixed type, after several days, exfoliation of necrotic mucosa is followed by appearance of voluminous viscous secretions. Inhalation burn cases frequently show large amount of secretons. In all cases bronchial toilet was performed repeatedly and no case developed sever bronchopneumonitis or significant respiratory dysfunction. The above findings show that it is very important to perform frequent bronchial toilet procedures, using a bronchofiberscope to maintain the integrity of the airway.

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Tracheobronchial involvement of esophageal carcinoma was estimated in 40 patients by pre-operative fiberoptic bronchoscopy. Fiberoptic bronchoscopic findings were classified into four types by the grade of tracheobronchial involvement. In the first type, class (⫲), tumor protrusion into the tracheobronchial lumen was found. In the second type, class (+), bulging and other mucosal changes, such as hyperemia or granulation of the tracheobronchial wall were found. In the third type, class (±), either bulging or mucosal changes was found. In the fourth type, class (-), there were no abnormalities. We supposed that class (⫲) and class (+) show tracheobronchial invasion of esophageal carcinoma, and no invasion in class (±) and class (-). In 34 patients, who underwent operation, preoperative staging by computed tomography (CT) and fiberoptic bronchoscopic findings were correlated with surgical findings. Fiberoptic bronchoscopy correctly identified 15 of the 16 patients with tracheal invasion and 17 of the 18 patients without invasion (accuracy 94.1%). Fiberoptic bronchoscopy also correctly identified 12 of 14 patients with bronchial invasion and 15 of 20 patients without invasion (accuracy 79.4%). This result was equal to the results by CT staging. In the esophageal carcinoma patients with tracheobronchial involvement, fiberoptic bronchoscopy showed the degree of invasion. We confirm that pre-operative fiberoptic bronchoscopy is very important for the management of esophageal carcinoma patients with tracheobronchial involvement.

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Eleven adult mongrel dogs were injected fibrin glue mixing with X-ray contrast agent (Hytrast) to those unilateral lobar bronchi. Three of them were observed by chest-X ray and a bronchoscope, and eight of them were pathologically examined. From the chest X-ray and bronchoscopical examination, fibrin glue in the proximal large bronchi disappeared within 3 days after fibrin glue injection. and one of peripheral lung did within 7 days after fibrin glue injection. In this period temporary atelectasis were observed in these lobes. From the pathological examination, fibrin glue disappeared in the lobe a week after fibrin glue injection. In each two lobes one and two weeks after the injection, organizing pneumonia were found here and there in different degrees, which caused by fibrin glue. In two lobes four weeks after the injection, focal fibrosis areas were found as the result of the inflammation. It was concluded that in the method of the embolization of the bronchus related to the air leak by fibrin glue, not only bronchial obstructing function by injected fibrin glue but also the inflammation caused by it in the peripheral lung area participated in the healing of the air leak.

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Two different methods of topical lidocaine anesthesia for bronchoscopic examinations were tried and compared with current methods. One hundred and two cases were randomly divided into following four groups ; A : 7ml of 4% lidocaine was sprayed with a Jackson's laryngotracheal sprayer (30 cases), B : 7ml of 2% lidocaine was sprayed with the sprayer, followed by intratracheal instillation of 2ml of 2% lidocaine (21 cases), C : (spray tube method) After pharyngeal anesthesia was obtained by 0.6ml of 8% lidocaine, 5ml of 4% lidocaine was sprayed through the spray tube (PW-5L, Olympus, Tokyo) via the bronchoscope (22 cases), D : (laryngotracheal anesthesia kit method) After pharyngeal anesthesia, the laryngotracheal anesthesia kit (LTA 360, Abbott) was intubated, through which 5ml of 4% lidocaine was sprayed (29 cases). Supplemental lidocaine was given by way of the working channel of the bronchoscope (2% lidocaine 2ml each time) when coughing developed. Significant differences were observed in the dosage of lidocaine employed for bronchoscopy among four groups, i. e., A : 374±43mg, B : 322±20mg, C : 226±25mg, D : 210±15mg. The best state of anesthesia was achieved in group D. No significant difference was seen in serum lidocaine concentration among the groups. No significant relationship was observed between serum lidocaine concentration and dosage of lidocaine administered, or between serum lidocaine concentration and state of anesthesia. Difficult intubation and laryngotracheal injury were the complications observed in group D. The spray tube method and the laryngotracheal anesthesia kit method are more appraisable than current methods.

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It has been generally considered that specimens obtained by transbronchial lung biopsy (TBLB) are insufficient to reveal findings in the bronchioli. For this reason, open lung biopsy is recommended to make a definite diagnosis of BOOP. But we can not always perform open lung biopsy in patients suspected of BOOP. Only one or two sections of each TBLB specimen are observed histologically in the routine laboratory examination. We prepared 50 serial sections from each paraffin-embedded block and stained every ten sections with hematoxylin-eosin staining (step sections). Remaining slides were stored so that special stains could subsequently be performed. This study was undertaken to evaluate the usefulness of TBLB in the diagnosis of BOOP by using step sections. Examined with step sections, we could detect bronchiolitis obliterans (BO), organizing pneumonia, and interstitial pneumonia more clearly in 4 cases suspected of BOOP. We concluded that making step sections of the TBLB specimens is a useful method in cases suspected of BOOP and that we can make a diagnosis of BOOP in some cases, if we interpret the histological findings of TBLB combined with the clinical features.

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Thirty-five cases with peripheral pulmonary nodules on a chest radiograph were examined by bronchography and thin-section high resolution CT. With CT examination nodules 2cm or less in size, in 5th order bronchus can be identified in the peripheral zone of upper lobe segments (particularly S^1, S^<1+2>a, b), but in middle or lower lobe segments, frequently not even 4th order bronchus can be identified. In the differential diagnosis of nodules, CT cannot revealed as detailed bronchial changes as bronchography, therefore margin characteristics and pleural indentation are important for diagnosis.

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Bronchoscopic findings of bronchial mucosal protuberances in three patients with bronchial arterial dilatation demonstrated by angiography were reported. An unexpected massive bleeding was seen after biopsy the mucosal protuberance in the first patient. Microscopic examination of the biopsy specimen revealed that it contained a piece of arterial wall. Owing to this experience, massive bleeding due to biopsy could be avoided in the following two patients. The endoscopical fingings of the mucosal protuberance caused by bronchial arterial dilatation were characterized by localization in the middle lobe bronchus in three cases and also the upper lobe bronchus in one. In addition the mucosal protuberance had a hemispherical shape with smooth tensioned surface consisting of normal mucosa. Some showed slightly elongated shape along the longitudinal axis of the bronchus and some showed elastic caving by compression with the tip of the forceps. Pulsation could be observed in some case by careful observation. It is extremely dangerous to make a bronchoscopical punch biopsy from the protuberances caused by submucosal vessels, especially bronchial arterial dilatation. Therefore, biopsy from any mucosal protuberance should be avoided, if there is a possibility of this kind of disorder.

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A 12-year-old boy had congenital cyanotic heart disease (dextrocardia, DORV, mitral atresia, pulmonary atresia, ASD and PLSVC) and repeatedly experienced hemoptysis, even after embolization of a bronchial artery using Gelfoam sponge. Using a bronchoscope, an exposed blood vessel was observed in the membranous part of the truncus intermedius. Selective bronchial arteriography revealed dilatation of a branched bronchial artery at the height of the right 4th intercostal space, and there was also remarkable collateral blood flow. When embolization of this artery was performed using Ivalon, the peripheral collateral blood flow almost completely disappeared. Bronchoscopic examination carried out after this technique also confirmed that the exposed blood vessel had disappeaered. There was no recurrence of hemoptysis even 21 months after the embolization procedures. A survey of the literature revealed only 4 case reports of bronchial artery embolization as treatment of hemoptysis in patients with congenital heart disease. None of those reports included observation of the course of the airway lesions.

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A 40-year-old man, who had complained of cough, was admitted to our hospital after a bronchial tumor was detected at an other hospital. Bronchoscopic examination revealed a polypoid tumor protruding from the orifice of the lingular bronchus, which narrowed the left upper lobe bronchus. Sleeve-lobectomy of the upper lobe of the left lung was performed on the suspicion of adenoid cystic carcinoma. Pathologically, the resected specimen revealed a tumor growing intraluminally covered with mucosa which did not invade the bronchial cartilage. Tumor cells showed features of oncocytoma microscopically and ultrastructurally, but on the other hand, tumor cells also showed the findings of bronchial mucous gland adenoma, therefore it was understood to be an intermediate tumor between oncocytoma and bronchial mucous gland adenoma. Both tumors are so rare that very few cases have been reported. This case has shown no recurrence 10 months after surgery.

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A case of endobronchial metastasis of carcinoma of the tongue is reported. A 52-year-old man was admitted complaining of hemosputum. The right half of his tongue had been resected on a diagnosis of carcinoma of the tongue six months ago. A chest X-ray showed atelectasis of middle and lower lobes of the right lung. Fiberoptic bronchoscopy revealed endobronchial tumors located both in the truncus intermedius and in the left upper division bronchus. These tumors were considered as endobronchial metastasis from carcinoma of the tongue, based on the histological finding. Following three courses of chemothrapy, the tumors decreased in size. Seven months later, a chest X-ray demonstrated atelectasis of the right upper lobe. Fiberoptic bronchoscopy discovered a reddish polypoid tumor in the right upper lobe bronchus, which was again regarded as endobronchial metastasis from carcinoma of the tongue. Besides the rarity of kind of metastasis, this case is worth being reported since consecutive observation using fiberoptic bronchoscopy enabled us to recognize the endobronchial spread of the tumor.

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Only 8 cases of endotracheal hamartoma have been reported in the world literature, including the present case. A 63 year old male was referred to our hospital with a chief complaint of stridor. He had undergone hemodialysis for 10 years. Chest X-ray suggested a mass in the upper trachea and tomography indicated that the lesion was protruded from the left wall of the trachea. Bronchoscopy revealed an apparently polypoid tumor at the upper part of the trachea. Histological examination of the biopsy specimen suggested tracheal chondroma. However the autopsy findings yielded a diagnosis of endotracheal hamartoma. which contained some other components.

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Three cases of pathogenetically different bronchoesophageal fistula are reported. Case 1 was a 56-year-old man in whom a bronchoesophageal fistula was pointed out by a chance esophagogastrography. At operation, fistulous communication was found between the middle third of the esophagus and the superior basal segment of the right lung. The bronchoesophageal fistula was diagnosed as Braimbridge type I. Case 2 was a 71-year-old man with chronic empyema associated with both bronchopleural and esophagopleural fistule. In this case, it was suggested that chronic inflammatory process in pleural space caused both bronchopleural and esophagopleural fistule, resulting in bronchoesophageal fistula. Case 3 was a 33-year-old woman diagnosed as having adenocarcinoma of the right lung. After three courses of chemotherapy, chest pain and cough developed. Bronchoscopic and esophagoscopic examinations revealed a bronchoesophageal fistula. In this case, it was suggested that necrosis of the paraesophageal lymph nodes induced by chemotherapy caused the fistulous formation connecting the esophagus and the bronchus.

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Herpes simplex virus pneumonia in a patient with adult respiratory distress syndrome during the chemotherapy for malignant lymphoma was reported. Many herpes infective cells including those with intranuclear inclusions, which were stained with herpes type II monoclonal antibody, were obtained by tracheal aspiration via a endotracheal tube. Autopsy revealed both herpes simplex virus pneumonia and pneumocystis carinii pneumonia.

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A 61-year-old woman underwent right pleuropneumonectomy for malignant mesothelioma. The chest drainage tube was removed four days after the operation. Although she initially did well, bronchopleural fistula developed at the bronchial margin about three weeks after the operation. A chest drainage tube was inserted. Two weeks late, oxycell cotton was put on the bronchopleural fistula and methyl cyanoacrylate was injected over the oxycell cotton through the instrumentation channel of a bronchofiberscope. Methyl cyanoacrylate was expectorated one day after, but the air leakage stopped four days late. The chest drainage tube was removed 13 days after the injection of methyl cyanoacrylate. The result suggests that methyl cyanoacrylate is useful for the control of bronchopleuralfistula.

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A 75-year-old male had undergone a left pneumonectomy following neoadjuvant chemotherapy with CDDP for a squamous cell carcinoma. The postoperative course was complicated by renal insufficiency and respiratory failure. On the 4th postoperative day, tracheostomy and mechanical ventilation were required. A bronchofiberscope showed a minor aperture in the left main bronchial stump, confirming the diagnosis of bronchopleural fistula at the 8th postoperative day. Endoscopic application of fibrin glue was attempted in vain. Because the air leakage continued, an omentopexy with thoracoplasty was performed 3 weeks after the first operation. The patient made an uneventful recovery.

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A 28-year-old man had a chest radiogram showing a band shadow in the right middle field. A CT scan demonstrated a branched structure with distal hyperinflation in the apical segment of the right lower lobe. At bronchoscopic examination there was no identifiable orifice for the right B^6_c bronchus. There was what appeared to be a B^6_a orifice in the truncus intermedius and a B^6_b orifice opposite the B^7 orifice in the right lower lobe bronchus. These orifices were comfirmed by bronchography, at which time the bronchi to S^6_a and S^6_b were filled and visualized, but there was no visualization of B^6_c. The coexistence of bronchial atresia and bronchial branching anomalies, displaced bronchi of B^6_a and B^6_b, in the same segment seems to allow more precise estimate of the time of the development of atresia. That is to say, the presence of bronchial anomalies in the same segmet led to the hypothesis that atresia occured during the 5th or 6th weeks of intrauterine life when the central airways are formed. We have also reviewed 43 cases previously reported in Japan to more clearly define this unusual entity.

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