Xanthine derivatives have been widely used in patients with asthma, but its mechanism of action is still uncertain. Our preliminary studies showed that theophylline at clinically effective concentrations had no direct effects on bronchial smooth muscle precontracted with acetylcholine or cholinergic neurotransmission in the airway, implying that the site of theophylline action might not be the smooth muscle. Since increased vascular permeability and subsequent airway edema may contribute to bronchoconstriction, we studied the effect of theophylline on histamine-induced vascular leakage in the rat airway. Vascular leakage was evaluated by point-counting mucosal vasculature stained with intravenously injected Monastral blue in whole-mount section of the trachea. Histamine produced an increase in vascular permeability. This effect was inhibited by pretreatment with theophylline in a concentration-dependent manner. Theophylline at 2.5mg/kg, which is supposed to be clinically effective but insufficient to inhibit phosphodiesterase, also decreased histamine-induced airway vascular leakage. These results suggest that clinical efficacy of theophylline could be explained at least in part by its inhibition of airway vascular leakage.

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In order to elucidate airway lesions and disorders of mucociliary transport system in Mycoplasma pneumoniae (M. pneumoniae) pneumonia, bronchofiberscopy, broncho-alveolar lavage (BAL), and aerosol inhalation cine-scintigraphy (AICS) were conducted in 6 cases of M. pneumoniae pneumonia. Bronchofiberscopic findings revealed redness and swelling of the bilateral bronchial mucosa in all cases and purulent secretion in 5 of 6 cases. Histological findings of bronchofiberscopic biopsy showed the desquamation and swelling of bronchial epithelial cells, broncho-bronchiolitis and alveolitis. The analysis of broncho-alveolar lavage fluid (BALF) contents demonstrated an increase of total cell counts and proportion of lymphocytes and neutrophils. AICS findings at one month from the onset disclosed that in 3 of 4 cases, either bolus formations or movements were absent, indicating severe impairment of mucociliary clearance. Futhermore, the impairment of mucociliary clearance still remained even 3 months from the onset in one subject. These findings suggested that there were both extensive and severe airway disorders in M. pneumoniae pneumonia.

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To evaluate the utility of the relationship between peripheral pulmonary nodules (PPN) and the drainage bronchi, thin-slice computed tomography (CT) was used to study 44 patients with PPN less than 30mm in diameter. There were 24 patients with lung cancer and 20 patients with non-malignant lesions. Thin-slice CT images were examined by an extended scale (window level : -600, window width : 1900) and a slice thickness 2mm, using a high resolution image. The patients were divided into two groups. One group included 31 (70%) cases (17 lung cancers, 14 non-malignant lesions) with a fourth- to sixth-order bronchus sign. Another group included 13 cases (seven lung cancers, six non-malignant lesions) with no bronchial appearance. Transbronchial biopsy (TBB) showed lung cancer in 14 (82%) of 17 patients in whom a bronchial appearance was seen on CT and in only two (29%) of seven patients in whom it was no seen. The difference was statistically significant (p<0.001). Conversely, in non-malignant lesions, no significant correlation was found between the TBB yield and the relationship of the lesions to the drainage bronchi. Our results suggest that the bronchus sign on thin-slice CT is valuable in predicting the success of transbronchial biopsy. The presence of a bronchial appearance on thin-slice CT may be useful in determining if the workup should include transbronchial biopsy in patients with peripheral small lesions.

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Anastomotic stenosis due to growing granulation tissue at anastomotic margins of a non-porous type tracheal stent limit its routine clinical use. The granulation tissue is probably due to repeated mechanical stimuli brought by traditional non flexible margins of artificial tracheas to date rather than the mere presence of a foreign material in cotact with host tracheal stumps. Auther has tested a hyposthesis that flexible margins of an artificial trachea may prevent an excessive growth of granulation tissue, and may resultantly lead to long-standing patency of each anastomotic margins. With a control model made by a five cm long corrugated woven dacron artificial vascular graft with its entire inner surface coated with 0.5mm thick silicone rubber, a test model was evaluated in form that each end for anastomosis is left innerly uncoated by silicone rubber for 5mm so that mechanical stimuli be cushioned at each flexible margins. Mediastinal trachea as long as 10-cartilage-ring length each of 20 mongrel dogs were replaced by end-to-end anastomosis. Growth of granulation tissue at each anastomotic margins was significantly less and slower in the experimental group, which resultantly yielded longer survival than the control group's, i. e., 260 vs. 44 days (p<0.01). Two out of 12 dogs surviving the surgery in the experimental group survived 17 months after surgery with anastomotic patency rate up to 50%. With passage of time following surgery the preventive effect of the experimental model was statistically valid til four months (p<0.05), but not thereafter because of delayed but still growing granulation tissue. The latter phenomenon was probably due to the gradual loss of the flexibility of the margins along with formation of some granulation tissue, which in turn caused mechanical stimulations at itself. Further considerations are needed for the anastomotic margins to assimilate within a few weeks after implantation with the host tissue.

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Mucosal bridging in the digestive tract is common in colonic inflammatory diseases, but is rarely observed in the bronchus. We reported five cases of bronchial mucosal bridging. The first case was a 71-year-old male with squamous cell carcinoma. Bronchoscopic examination after radiotherapy revealed a mucosal bridge in the right main bronchus where stenosis and mucosal adhesion had been observed before treatment. In the second case, a 58-year-old male with small cell carcinoma treated with systemic chemotherapy, several mucosal bridges were seen in the left lower bronchus after improvement of total atelectasis of the left lung. The third case was a 64-year-old male with squamous cell carcinoma. After concurrent chemoradiotherapy, the tumor in the left upper lobe bronchus was diminished and a mucosal bridge was revealed. The fourth case was an 86-year-old male, small cell carcinoma, treated with etoposide orally and radiotherapy. After the treatment, his tumor decreased in size and three mucosal bridges between the tumor and bronchial mucosa were revealed. The last case was an 63-year-old female. Her small cell carcinoma was treated with radiotherapy because of recurrence. After treatment two mucosal bridges were revealed on the former tumor bed. In the past three years, we have performed follow-up bronchoscopy for 74 cases with lung cancer, and the incidence of mucosal bridging after chemotherapy and/or radiotherapy was 6.7%. We considered the formation of the mucosal bridges as follows. First, a cancer lesion comes in contact with the opposite wall of the bronchus due to extramural pressure such as lymphadenopathy or tumor growth itself. Second, the cancer cells invade to the opposite bronchial wall or simple adhesion occurs, and partial continuity of opposite sides of the bronchial wall is made. Then, the cancer cells decrease in number or are totally evadicated by chemotherapy and/or radiotherapy, and adherent mucosa is stretched to form mucosal bridges, as the lumen of the bronchus returns to its normal size.

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A 40-year-old man was admitted to our hospital because of an obstructive pneumonia of the right lower lobe. He had a history of subacute polyradiculoneuritis, due to which the systemic sensory and motor disturbance persisted. Bronchoscopic examination revealed an elevated lesion that obstructed the right basal bronchus. The lesion had an irregular, edematous and reddened surface with white debris, and the findings suggested a malignant tumor. Biopsy specimens, however, showed partial exfoliation of bronchial epithelium and edematous stroma with marked infiltration of neutrophils and high vascularity. Food remnants were also recognized. We made a diagnosis of bronchial inflammatory polyp due to a foreign body. The patient was given a course of antibiotics for obstructive pneumonia. Corticosteroids were also administered because of severe adverse reactions caused by the antibiotics ; a drug-induced hepatitis and a drug eruption. The bronchofiberscopy after recovery from the pneumonia showed an almost complete disappearance of the polyp lesion. This may have resulted from the antibiotic and/or corticosteroid therapy. The present case illustrates the possibility that antibiotics and/or corticosteroids might be useful as the first step of treatment for bronchial inflammatory polyp.

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A 38-year-old man was admitted with pneumonia. Bronchoscopy revealed small, lobulated, pale nodular tumors in the bilateral main bronchi. The tumor cells were identified as granular cell tumor by immunohistochemical studies with S-100 protein and neuron-specific enolase. The relation between the granular cell tumor and repeated pulmonary infections was unclear. Either resection or bronchoscopic removal is the preferred treatment, but long-term follow-up by bronchoscopy may also be appropriate.

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A case of a 72 year old female who suffered severe hypoxemia and dyspnea due to obstruction of the left main bronchus by a squamous cell carcinoma is reported. Since ventilation with 100% oxygenation was necessary, irradiation by Nd : YAG laser for the opening of the central airway could not be performed. Instead, intratumoral ethanol injection was applied for the sphacelation of the tumor, but obtained no effect. To improve the hypoxemia, a 12Fr. suction tube was inserted between the tumor and the bronchial wall, which improved her condition immediately. After 60 Gy. irradiation malignant cells were still recognized, therefore to prevent restenosis we inserted a Dumon silicon stent into the left main bronchus. Eleven months has passed and there has been no trouble except for one episode of viscous sputum causing stenosis of the stent. There has also been no particular problem in the fixation of the stent. It can be concluded that this is a safe and easy way to prevent stenosis of the central airway due to malignant tumors.

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A 22-year-old male was transferred to a hospital after a motorcycle crash. He was in serious condition on admission with brain injury, bilateral hemopneumothorax, mediastinal and subcutaneous emphysemas, fracture of the right clavicle and paralysis of the right brachial plexus. His general condition improved, but one month after the injury, radiologic studies revealed complete atelectasis of the right lung secondary to stenosis of the right main bronchus by traumatic disruption. Bronchoscopy disclosed that the right main bronchus was markedly stenotic due to granulation tissue. An Nd-YAG laser treatment of the stenotic lesion was done via fiberoptic bronchoscopy, but this procedure could maintain the airway for only a few days because of restenosis due to granulation tissue. Until the operation for right brachial plexus paralysis performed at our hospital three months after the injury, treatment with Nd-YAG laser vaporization as adjuvant therapy was performed four times. Ten more laser vaporization sessions were followed by surgical repair of bronchial rupture (circumferential resection of the right main bronchus with end-to-end anastomosis) performed nine months after the injury. The postoperative course was uneventful. Seven months after the operation, a bronchoscopic study revealed that the air way was patent and no granulation was observed.

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The patient was a 55-year-old male who had bloody sputum 9 years after thyroid cancer had been resected. As bronchoscopy revealed a tumor in the orifice of the lingular bronchus of the left lung, endoscopic Nd-YAG laser therapy was performed. At first, Nd-YAG laser treatment performed every 2 months maintained a good quality of life (QOL). However, after 12 months the tumor projected into and markedly narrowed the left main bronchus. The orifice of the lower lobe bronchus was also obstructed by tumor. As laser treatment has its limitations, a stent was placed in the basal bronchus. Although the tube slipped out and had to be replaced, no bleeding was observed upon reinsertion. Neither granulation nor atelectasis of the upper lobe or S6 segment developed after insertion. Concomitant use of the Nd-YAG laser and an indwelling stent tube maintained a good QOL for about 2 years.

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A Case of pulmonary eosinophilic granuloma with elevated level of eosinophil cationic protein (ECP) in bronchoalveolar lavage fluid (BALF) was reported. A 26-year-old male was admitted for further examination of abnormal findings on chest roentgenogram. Chest roentgenogram and chest CT showed reticulonodular and multiple cystic shadows in the bilateral upper and middle lung fields. The specimens obtained by TBLB revealed granulomatous lesions with infiltration of eosinophils and histiocytes, positive for S-100 protein staining. The number of eosinophils and CD1a positive cells increased in BALF. The ECP content, measured by a radioimmunoassay, also increased in BALF. Following steroid treatment, radiological findings improved with decrease in the number of eosinophils and ECP content in BALF. Therefore, it is suggested that activation of eosinophils may be involved in the pathogenesis of pulmonary eosinophilic granuloma.

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A 43-year-old man was admitted our hospital complaining recurrent pneumonia for 7 years. Obstruction of the right main bronchus was detected roentgenographically and bronchoscopically. Diagnosis could not be obtained, and thoracotomy was carried out. Incision of the right main bronchus revealed a foreign body in the bronchus which was the cap of a pen. Since he was an epileptic, it was supposed that the cap must have been in his mouth and was aspirated into the bronchus during an epileptic fit.

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A 64-year-old female complained of a cervical mass. We palpated an elastic-hard tumor in the right lobe of the thyroid and a hard tumor in the left lobe of the thyroid. The results of thyroid hormonal analysis showed hyperthyroidism. The result of aspiration biopsy cytology of the right lobe was class III but class V in the left lobe. Cervical CT showed an air space above the right clavicle. We performed total thyroidectomy and bilateral modified neck dissection. At operation we found 3 air-filled cysts and two pedicles connected to the right side of trachea. These 3 cysts, which were filled only air, were resected. We diagnosed these cysts as congenital bronchogenic cysts.

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A 68-year-old man with a smoking history of 30 cigarettes per day for 42 years was referred to our hospital for further examination of sputum cytology class V (squamous cell carcinoma). He had histories of sigmoid colon cancer, lung cancer (squamous cell carcinoma) and gastric cancer in this 5 years. Bronchoscopic findings showed 5 scattered lesions from trachea to left main bronchus. Microscopic findings of each biopsied specimen revealed squamous cell carcinoma. Some of them included carcinoma in situ, which confirmed the diagnosis of multiple primary tracheobronchial cancers.

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Upper airway obstruction due to bilateral abductor vocal cord paralysis resembles bronchial asthma in that wheezes and dyspnea are found. A 71-year-old man with cerebral infarction presented severe stridor at both inspiratory and expiratory phases. Treatments of xanthine and β-stimulating agents failed to improve his symptoms. A bronchoscopic examination disclosed bilateral abductor vocal cord paralysis. Immediately tracheostomy was performed to prevent asphyxia. We suggest that bronchoscopic examination is useful to disclose the origin of upper airway obstruction which is not improved by an administration of bronchodilating agents.

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