Cough is a very common presenting symptom in general practice and the chest clinic, yet the mechanisms of cough and effects of drugs on cough have been controversial. The authors examined the effects of inhalation of procaterol, ipratropium bromide and naphazoline on cough induced by tartaric acid and capsaicin in 9 normal volunteers. Increasing concentrations of tartaric acid and capsaicin were inhaled for 15 seconds by tidal breathing with a nose clip every one minute until five or more coughs were elicited. The cough threshold was defined as the lowest concentration of each cough inducer that elicited five or more coughs. Partial and maximum expiratory flow-volume curve was measured after measurement of cough threshold to ensure bronchodilating effect of each tested drug. The geometric mean value of cough threshold to tartaric acid was 0.99 (GSEM, 1.36), 0.92 (GSEM, 1.61), 1.07 (GSEM, 1.39) and 0.92 (GSEM, 1.51)% in controls, after 40μg of ipratropium bromide, after 20μg of procaterol and after 1 mg of naphazoline, respectively. There was no significant difference for each value. The mean cough threshold value to capsaicin was 4.19 (GSEM, 1.39), 4.52 (GSEM, 1.35), 5.27 (GSEM, 1.39) and 4.52 (GSEM, 1.35)μ mol, respectively. There was no significant difference among them. Maximum expiratory flow at 25% FVC on partial expiratory flow-volume curve (PEF_<25>) was significantly increased by procaterol and ipratropium bromide when cough was induced by tartaric acid. However PEF_<25> was not significantly increased by procaterol, ipratropium bromide or naphazoline when cough was elicited by capsaicin. These results suggest that cough sensitivity is not modulated by beta-2-adrenergic, muscarinic or alpha-2-adrenergic activity, and that bronchodilators are not effective on induced cough in normal airways. In addition, it is suggested that capsaicin induces mild bronchoconstriction at a concentration producing cough.

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We performed a combination of bronchoscopic curettage and, broncho-alveolar lavage (BAL) in 70 cases with peripheral solitary shadows admitted after October, 1985. Definite diagnoses were made in 69 cases after performing this method together with operations or autopsies : malignant tumors 28 cases (40%), general bacterial infections. e.g. lung abscess. infected bronchectasis pneumonia etc. 24 cases (35%), pulmonary tuberculosis 13 cases (19%) and others 4 cases (6%), Infectious diseases account for more than 50% of peripheral solitary shadows and the rate of tuberculosis is still high. By sputum cytology, conventional X-ray examinations and this method. final diagnoses were obtained in 47 cases (67%). The diagnostic percentage for each disease were ; 50% for malignant tumors, 88% for general bacterial infections excluding the detection of causative bacterira, 85% for tuberculosis and 25% for other diseases. Diagnostic rate of malignant tumors was 57% after including curettage, BAL fluid cytology and transbronchial lung biopsy (TBLB). But the diagnostic rate of this method was superior to that of TBLB alone. No metastatic lung tumors could be diagnosed by this method and TBLB. In 8 (22%) out of 37 infectious disease cases the results of sputum and BAL fluid culture coincided. By including BAL fluid stain and culture, causative bacteria were detected in 25 cases (68%). Causative tuberculosis bacilli, anaerobic bacteria and fungi were detected more frequently in BAL fluid than in sputum. These results were considered to show the present state, limitations and future problems of this method.

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The frequency and background of fever after 742 transbronchial biopsies were studied. Fever of 38℃ or higher, lasting for more than 4 days, occurred in 16 cases (2.2%). Of 16 cases, 10 had lung cancer, and endobronchial obstruction or stenosis was seen in 9 of the 10. Of these 9 cases, 7 had epidermoid carcinoma, and 2 had small cell carcinoma. The frequency of fever tended to be higher in lung cancer cases who had endobronchial obstruction or stenosis, especially when transbronchial brushing was performed in combination with biopsy. There are two reasons for this tendency, impaired local defense of the bronchial mucosa resulting from direct invasion of cancer and direct trauma to the bronchial mucosa which has been shown to be severer after brushing than biopsy. Since the combined use of transbronchial biopsy and brushing for lung cancer cases who have endobronchial obstruction or stenosis might develop serious infectious diseases, use of antibiotics is thought to be necessary immediately after these procedures.

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Intratumoral injection of absolute (99.5%) ethanol via a flexible bronchofiberscope was attempted on 10 cases with tracheobronchial stenosis or obstruction by neoplasia. Out of 7 cases with lung cancer, ethanol injections were effective in 1 case, and temporarily effective in 3 cases, while they were ineffective in the others. Though the results were ineffective in pulmonary metastasis, effects were obtained in a case of tracheal cancer and one of tracheal papillomatosis was improved. In some cases, radio- or chemotherapy were performed in combination with ethanol injection. There were no complications except for mild cough. This method was effective against polypoid proliferative tumors but ineffective for superficial or submucosally infiltrating tumor. However, even in effective cases, long term prognosis was not so good. Though it is palliative, intratumoral ethanol injection can be useful for bronchoscopic treatment from the standpoint of the patient's quality of life.

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Clinical aspect, bronchoscopic and bronchographic findings of a series of 89 consecutive patient with middle lobe syndrome were reviewed. As underlying diseases of middle lobe syndrome, lung cancer was detected in 2 cases, while tuberculosis and broncholithiasis were seen in 1 case each. The incidence of middle lobe syndrome was higher in middle aged subject and females had a 2.5 times higher incidence than males. Bronchoscopy was performed in 43 cases and stenosis or obstruction of the middle lobe orifice was determined in 32.6% of examined cases. Bronchography was performed in 37 cases and revealed abnormalities in 91.9% of examined cases. By means of the lateral view on bronchography, a length and a width of middle lobe bronchus and the angle between truncus intermedius and middle lobe bronchus were measured. The length was significantly longer and the angle was significantly smaller in patients with middle lobe syndrome than in normal controls (22.6mm vs. 14.6mm, p<0.01 and 38° vs. 47°, p<0.05). The width was, however, not significantly different. There is virtually no report comparing middle lobe syndrome with other disease although there are several comparison of middle lobes with other lobes. These results shed some light on the middle lobe bronchi of patients with middle lobe syndrome.

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The Subjects consisted of 6 patients whose bronchial stenosis had been confirmed by bronchoscopy. First, lung sounds were recorded using an electric condenser microphone at the neck over the trachea and at both midclavicular lines at the 3rd intercostal space. We analyzed the sound spectrographs, the time expanded wave forms and power spectrum. Then, the coherence functions among these 3 positions were calculated as the correlation analysis of frequency domain. The stenotic regions were more centrally located than the segmental bronchi. Except for only one case, the fiberscope was not able to pass the stenotic regions. The continuous adventitious sounds due to bronchial stenosis were revealed to be fixed monophonic tones in all cases. The sound intensity was maximum at the neck over the trachea, and minimum at the opposite chest wall. According to the analysis of coherence functions, the stenotic sounds were well transmitted to the neck over the trachea. It was concluded that the existence of stenotic regions must be considered when monophonic continuous sound which differ in the right and left chest walls are heard on auscultation, and the tracheal region is a very important location for auscultating and monitoring patients with bronchial stenosis.

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A 73-year-old man who had right lower lobectomy for right S^9 primary lung cancer four years previously was admitted to Tenri Hospital because of an abnormal shadow on chest roentgenogram. Bronchoscopic biopsy revealed small cell carcinoma from left B^<1+2>, and early stage squamous cell carcinoma in left B^9. These synchronous carcinomas responded rapidly and completely to chemotherapy and an endoscopic YAG-Laser therapy. We reviewed and summarized 7 cases of multiple primary lung cancers in our hospital. Our series included 4 cases in which both lung cancers were resected. The incidence of multiple primary lung cancers tends to increase in time. We concluded that postoperative follow-up studies containing bronchoscopy are essential for detection of second primary lung cancer.

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A case of double primary early lung cancer (squamous cell carcinoma and adenocarcinoma) exisiting very close to each other in one lobe was reported. A 46-year-old man employed in chromate manufacturing for 30 years and who had smoked 20 cigarettes a day for 9 years visited our hospital complaining of bloody sputum. Chest X-ray film showed no abnormal findings. Cytologic examination of his sputum revealed squamous cell carcinoma. Bronchoscopically the mucosa of the bifurcation between left B^8 and B^<9+10> was inflamed, and its surface was rough. Cytologic examination of the brushing specimen from the bifurcation revealed adenocarcinoma and squamous cell carcinoma. Left lower lobectomy and mediastinal lymph node dissection were performed. Microscopic findings of the resected material showed a squamous cell carcinoma on the bifurcation of left B^8/B^<9+10> and an adenocarcinoma in the left basal bronchus just beyond the bifurcation. These primary lesions were separated from each other by normal bronchial mucosa and there were no transitional portions between them.

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A 54-year-old male underwent resection of an oral tumor (squamous cell carcinoma) in 1984, and chest X-ray showed multiple cavitary shadows in January, 1987. After transient expectoration of large amounts of bloody purulent sputum, his general condition deteriorated and he was admitted to the hospital. Chest X-ray on admission showed multiple nodules with thin-walled cavities. Bronchofiberscopy showed fistula to the tumor cavity at the bifurcation of the right upper lobe bronchus and the truncus intermedius and the inner surface of the cavity showed a milky-white ventricle-like structure. The biopsied specimen from the inner surface of the cavity revealed squamous cell carcinoma, probably metastatic. There was a small aperture on the opposite wall of the cavity, which was identified to be right B3 bronchus by bronchography. There have been some reports of observation of the inner surface of cavities of primary lung cancer, but reports on metastatic cases are few. Our case is provides information on the mechanism of the development of the cavity.

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The patient was a 69-year-old female who complained of hemoptysis for six months. Chest X-ray film showed no abnormal findings. Bronchoscopy disclosed a protuberant lesion with an irregular surface at the orifice of the right main bronchus. With HE staining a biopsy taken from this lesion showed eosinophilic amorphuos material deposition in the subepithelial layer. With Congo-Red staining the deposition showed green birefrigence by polarizing microscopy, so the material was recognized to be amyloid. The amyloid was resisted to KMnO_4 so it was thought to be AL amyloid. Gastric and rectal biopses failed to demonstraited amyloid deposits, and the patient was free of any disease known to yield secondary amyloidosis. A diagnosis of a primary localized bronchial amyloidosis was made. Primary amyloidosis in the lung was divided into four types by Spencer. This case was classified of type I form (a localized deposit in the bronchus). This case coresponded to primary amyloidosis localized only in the bronchus and may be the first case peported in Japan.

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A 70-year-old man who, since 5 years ago, was being treated for a chronic pulmonary emphysema, was admitted in this hospital Neruosurgery Department with the diagnosis of subarachnoid hemorrhage. The postoperative period was complicated by aspirative pneumonia which was treated unsuccessfully with antibiotics and steroids. The patient was intubated through a tracheostomy tube and was referred to our department for mechanical ventilation. On a diagnosis of COPD and pneumonia (Pseudomonas), and in order to aspirate exessive lower airway secretions fiberopitc bronchoscopy study was performed. During this procedure sudden, progressive and generalized subcutaneous emphysema occured. The Bronchoscopy-tip impaction ruptured the membrane portion of the right main bronchus causing the mediastinal and subcutaneous emphysema. The bronchial membrane wound-closure was completed in a week, after having unilateral intubation through the left main bronchus. Sinse, fiberoptic bronchoscopy is becoming increasingly indispensable to decide the most appropriate therapeutic approach in patients with critical clinical conditions, sufficient care is necessary to avoid the above kind of complications.

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A Case of early adenoid cystic carcinoma of the lung is reported. The case was an 87-year-old female, who complained of low grade fever. Bronchoscopy was performed on the suspition of tuberculosis because an infiltrating shadow was found in the right upper lung field on the X-ray. A small prominent lesion was found at the orifice of the left lingular bronchus, and it was diagnosed as adenoid cystic carcinoma from biopsy specimens. This case was roentogenographi-cally classified as an early stage, and was the highest aged case of adenoid cystic carcinoma reported in Japan. Because of her advanced age, therapy was limited within conservative methods such as removal of the lesion with biopsy forceps and laser irradiations.

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A 61-year-old man was admitted to our hospital for detailed examination of an abnormal shadow on chest X-ray film. Chest X-ray showed a mass shadow in right S^1. Bronchoscopy revealed a tiny smooth tumor of the bifurcation of left B^6 and the basal bronchus but no abnormal lesion in right B^1. The tumor was 1×1×2mm in size and bronchoscopic biopsy was performed. The histology of the tumor was leiomyoma. Cytological examination of right B^1 by bronchoscopic brushing showed lung cancer. Right upper lobectomy was performed. The histological diagnosis of the resected spiecimen was large cell carcinoma. Bronchoscopic examination including biopsy was performed 5 month later, and there was no evidence of any residual or recurrent leiomyoma. This is the smallest endobronchial leiomyoma reported and it is the second case associated with lung cancer in Japan.

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Tracheal leiomyoma is an extremely rare disease, and few reports are found in the Japanese or international literature. The authors report one case diagnosed as tracheal leiomyoma and successfully treated by endoscopic Nd-YAG laser therapy. The patient was a 14-year-old boy, who complained of wheezing at night and bloody sputum. Chest X-ray films showed a tracheal tumor, and other examinations revealed a tracheal leiomyoma. We performed endoscopic Nd-YAG laser therapy for this tumor. The tumor disappeared, and tumor recurrence has not recognized for 21 months. Endoscopic Nd-YAG laser therapy for a tracheal benign tumor should be performed as the first treatment of choice, especially considering the risk of surgical therapy.

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From January 1, 1988 to December 31, 1989, 5 patients were admitted to our hospital with foreign bodies in the tracheobronchial tree. The age range was 12-79 (average 52.6 years) and all 5 cases were male. Of these patients, 3 had complained of a productive cough and 2 had no complaints. The location of these foreign bodies was in the right side, case 1 was in the main bronchus, cases 2 and 3 were in the middle lobe bronchus, cases 4 and 5 were in the truncus intermedius. Of these foreign bodies, three cases were false teeth, one case was a natural tooth that had fallen out and the other was a carpentry nail. The period during which the foreign body had been in place ranged from 1 hour to more than 7 years. Four cases of these were removed by foreign body forceps inserted through the bronchofiberscope and the other case was resected with the right middle lobe.

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ICU patients frequently have a reduced respiratory and circulatory reserve, and the hypoxemia induced during endoscopic bronchial toilet or associated circulatory changes, such as hypertension and arrythmia, are particularly perilous. In order to enhance safety, an endotracheal tube is generally inserted under general anesthesia and the endoscopic procedure is performed under controlled ventilation. It is, however, difficult to perform endotracheal intubation without affecting the circulation, and furthermore, the endoscopy is not facilitated and the ventilatory resistance increases during the endoscopic procedure. The laryngeal mask airway has recently come into use for general anesthesia, and is a form of new airway that is not directly inserted into the trachea, allowing the effects of insertion on the circulation to be reduced. Also, because of the wide inside diameter and short overall length of the tube, endoscopy becomes smoother and ventilation during the procedure is made easier. Using this laryngeal mask airway, we performed successful endoscopic bronchial toilet for atelectasis in three patients admitted to our ICU.

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