The anatomical investigation about the respiratory bronchioles which branch from pre-terminal bronchioles was performed with an inflated-fixed human lung specimen. Eight lung blocks obtained from a normal fixed lung were cut into slices 0.5mm thick and were radiographed in contact with a fine grain film. The radiographs were digitalized and magnified by the image analyzing machine and tracing procedure of intralobular bronchiole was performed with the magnified radiographs. In this study, we examined thirty-six secondary pulmonary lobules in the subpleural area, and we found that the number of respiratory bronchioles branching from pre-terminal bronchioles ranged from 0 to 6 with an average of 1.6 per one lobule. Although these respiratory bronchioles could be observed in any branching generation in secondary lobules, we found that these branches, especially those with retrograde courses, supplied the proximal portions of the lobules in about 36% of cases. According to these facts, we conclude that respiratory bronchioles branching from pre-terminal bronchioles can be considered as daughter branches of the lobule and have a role to supply the proximal portion of the lobule.

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Fiberoptic bronchoscopy was performed on 27 cases. Local anesthesia achieved with a 2% solution of Lidocaine, and bronchial aspirates were collected throughout the procedure. The drug concentration of Lidocaine in these aspirates was between 0.017 and 1.5mg/ml ; the mean was 0.6mg/ml. The in vitro study revealed that Lidocaine inhibited the growth of Mycobacteria in the above-mentioned range, particularly when more than 1mg/ml. The growth inhibition of Mycobacteria was dependent on the drug concentratin of Lidocaine and duration of exposure. It may be concluded that in order to increase the diagnostic yield of pulmonary tuberculosis using fiberoptic aspirates, it is important to decrease the contamination of Lidocaine, and perform the routine culture method as soon as possible.

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The author investigated cytograms and bacterial examinations of bronchoalveolar lavage fluid (BALF) in 16 leukemia and 9 malignant lymphoma cases with abnormal shadows on chest X-ray. Predominant types of abnormal shadows were diffuse in leukemia and massive or focally substantial in malignant lymphoma. Increase of macrophage population and decrease of lymphocyte population were characteristic features on cytograms. Tumor cells were found in 18.8% of leukemia cases and in 33.3% of malignant lymphoma cases. Infective organisms were detected in 37.5 and 22.2% of cases, respectively. An increase of red blood cells and erythrocyte-or-hemosiderin phagocytic macrophages indicating hemorrhage were detected in 18.8 and 11.1% of cases. Cytogram abnormalities such as predominant lymphocytes apart from the above 3 findings were found in 18.8 and 11.1% of cases. Whereas hemorrhage and infection were mostly seen after chemotherapy, tumor infiltration and cytogram abnormality were seen previously. Some abnormal findings were found in about 90% of all 25 cases, therefore investigation of BALF is a safe and beneficial method.

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Two cases of broncholithiasis were reported. Case 1 was a 60-year-old female who had hemoptysis and low grade fever. Chest roentogenogram showed a tumorous shadow with scattered calcifications in the right upper lobe. Bronchofiberscopic examination revealed severe stenosis with yellowish-white materials in the orifice of right B^2. After administration of anti-tuberculous agents, small stones were expectorated with cough, and the shadow in the chest roentogenogram almost disappeared. Case 2 was a 64-year-old male who had hemosputum. Chest roentogenogram showed right hilar calcification. Bronchofiberscopic obsevation revealed a yellowish broncholith protruding into the lumen of B^<10> with an inflammatory polyp. We could not remove the stone with conventional forceps because it strongly adhered to the bronchus. After antibiotic therapy, the bloody sputum was improved. The etiology of both cases was considered pulmonary tuberculosis. We considered that anti-tuberculous agents or antibiotics are useful for the broncholiths which can not be removed in theses cases.

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The authors report a rare case of endobronchial metastasis from prostatic cancer. A 63-year-old man initially complained of cough, then of dysuria, and was diagnosed as having prostatic cancer. Bronchoscopic examination revealed numerous endobronchial tumors. Biopsy revealed moderately differentiated adenocarcinoma. On the basis of immunohistological staining, the endobronchial tumors were diagnosed as metastases from prostatic cancer. The patient was treated with combination chemotherapy (cisplatin and etoposide) and complete remission was obtained. This case indicates the importance of evaluation of respiratory symptoms in the management of urologic cancers.

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Uvulopalatopharyngoplasty (UPPP) is one of the surgical treatments for sleep apnea syndrome. The site of the obstruction should be to definitely identified before treatment. We used bronchofiberscopic examination during drug-induced sleep in two patients, and have confirmed the location of the airway obstruction. In the first case, a 31-year-old man was admitted to our hospital for the treatment of somnolence and sleep apnea. He was 72.7% over his ideal body weight. Bronchofiberscopic examination was performed under sleep induced by thiopental sodium, 4mg/kg, administered intravenously. During sleep, the obstruction was observed clearly in the oropharynx and subsequent UPPP was performed successfuly. The second patient was a 54-year-old man, admitted for the treatment of sleep apnea. He was 81.4% over his ideal body weight. After administration of intravenous diazepam 0.1mg/kg, the site of obstruction was localized in the oropharynx, and we could foresee that UPPP would be therapeutic. Compaired to other reported techniques, such as manometry and acoustic echography, this procedure is easier to perform and is more definitive. Bronchofiberscopic examination under drug-induced sleep is a useful addition to the diagnostic work-up of obstructive sleep apnea syndrome.

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Among the complications of bronchofiberscopy, pulmonary edema is very rare. A 51-year-old female patient with a history of SLE was admitted because of dyspnea. During bronchofiberscopy and broncho-alveolar lavage (BAL), her dyspnea suddenly became severe and pulmonary edema developed. After artificial PEEP respiratory control, her general condition gradually improved. The background of this case included immunological abnormalities such a SLE, heart failure, hypoproteinemia and so on, and suggested that the pulmonary edema was induced by the bronchofiberscope procedure. The pathophysiological background of the patient must be considered before performing bronchofiberscopy or BAL.

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A 65-year-old man was admitted with high fever and skaking chill. Chest X-ray showed an infiltrative shadow in right upper lung field with an air-bronchogram, and serum CRP was markedly elevated. Bacterial pneumonia was diagnosed, especially due to pneumococcus. Inspite of treatment with piperacirine or imipenem, high fever continued and chest X-ray did not improved. Seven days after admission, bronchoalveolar lavage and transbronchial lung biopsy revealed this case to be eosinophilic pneumonia ; lymphocytes and eosinophils increased in bronchoalveolar lavage fluid, and biopsied specimens showed septal thickening and infiltration of eosinophils into alveolar septa and peripheral bronchioles. After administration of low dosage corticosteroids chest X-ray improved and high fever disappeared. This case was thought to be a rare case of eosinophilic pneumonia because it presented with shaking chills and high fever, but some microbial infections might not be neglected. Bronchoalveolar lavage and transbronchial lung biopsy were useful for the diagnosis of eosinophilic pneumonia.

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Solitary bronchial papillomas are rare endobronchial neoplasms. The authors reported two cases of solitary bronchial papilloma. One case was a 68-year-old male who presented with recurrent cough and fever. Bronchofiberscopy revealed a polypoid lesion with a smooth surface located at the orifice of the left lower lobe bronchus. Transbronchial biopsy revealed a transitional papilloma, and left lower lobectomy was performed. The other case was a 64-year-old male who presented with cough and bloody sputum. Bronchofiberscopy revealed a polypoid lesion with a granular surface located at the orifice of right B^<1+3>. Transbronchial biopsy revealed a squamous cell papilloma. Subsequent follow-up revealed no further changes were recognized.

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Dumon silicone stents were used in combination with YAG laser and/or rigid bronchoscope for dilation of the airway in two patients with stenosis of the main bronchus due to malignant disease and one with post-tracheostomy stenosis. Symptoms improved in two patients soon after the procedure and a good quality of life for over five and ten months each was obtained. In one patient retentioin of significant amounts of secretions was a problem in mechanical ventilation. The Dumon stent is useful for treatment of tracheobronchial stenosis because it is not limited to particular lesions and it can be removed easily. In addition, the stent is considered suitable for patients who can expectorate airway secretions.

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A 76-year-old woman was admitted to our hospital because of chest oppression, dyspnea, cough and sputum. Examinations revealed that the symptoms were due to complete obstruction of the right main bronchus caused by pulmonary metastasis of an extraskeletal myxoid chondrosarcoma which had been detected 9 years before. Treatment with biopsy forceps and Nd-YAG laser opened up a lumen in the right main bronchus. This disease is relatively rare. In addition, there have been no reports showing the polypoid growth as reported here.

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A 81-year-old man consulted his home doctor because of sudden dyspnea, and pneumothorax was diagnosed. As the collapsed left lung reexpanded, a mass shadow became apparent in the left middle lung field. After admission to our hospital, squamous cell carcinoma was diagnosed but he was evaluated as inoperable because of poor pulmonary function despite the fact that it was early stage lung cancer. Several days after admission, pneumothorax reccurred and tube thoracostomy was performed. Because of continuous massive air leakage in spite of two attempts at pleurodesis with OK-432, we tried bronchofiberscopic bronchial obstruction therapy (BBOT). Since obstruction of the lingular branch with a balloon catheter resulted in disappearance of the air leakage, this bronchus was judged to be responsible for the leakage of air. Some pieces of oxidized cellulose cotton were placed in the lingular bronchus using a fiberoptic bronchoscope. Immediately after the complete obstruction of the bronchus, the air leakage halted. Pleurodesis with OK-432 was once again tried successfully and the intercostal tube was removed on the fifth day after BBOT. In 8 cases treated successfully by BBOT in our institute, there has been no recurrence of pneumothorax after BBOT. Therefore, we recommend this therapy in cases of pneumothorax with continuous air leakage, before considering surgical treatment.

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A 71-year-old man was admitted to our hospital because of high fever and dyspnea. A chest X-ray film on admission revealed atelectasis of the right lung. Bronchofiberscopy showed a white polypoid lesion obstructing the right main bronchus and biopsy specimens showed squamous cell carcinoma of the lung. He was clinically diagnosed as Kartagener's syndrome because of situs inversus, bronchiectasis and chronic sinusitis. We demonstrated a lack of dynein arms of his bronchial cilia under electron microscopy. Only a few cases of Kartagener's syndrome with lung cancer have been reported. The relation between this syndrome and lung cancer has not been clear. Severe respiratory tract infection due to decrease in airway clearance sometimes prevents early diagnosis of lung cancer. It is better to treat patients with Kartagener's syndrome keeping the possibility of lung cancer in mind.

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A 55-year-old male case of malignant thymoma in which the initial condition was pericarditis followed by pleuritis and endobronchial metastasis after 1 year was reported. Although a definitive diagnosis was not obtained pathologically, the pericarditis and pleuritis was thought to be due to direct invasion of malignant thymoma. Both primary and bronchial lesions were diagnosed pathologically and the endobronchial lesion was thought to be metastatic from the primary lesion from the findings of computed tomography. After partial remission following combination chemotherapy, the patient was treated with curative radiation therapy mainly to the mediastinum. The primary lesion revealed no remarkable change in size during a period of one year and serositis was also controlled by direct local chemotherapy. Intensive chemotherapy is recommended to prolong the life of patients with malignant thymoma with invasion and/or metastasis. Adjuvant therapy such as G-CSF might be recommended in the future. This patient died of recurrence of pericarditis and of multiple organ failure caused by metastasis to the liver.

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