In fibrobronchocapnography (FBC), CO_2 sampling tubes are introduced into each lobar bronchial orifice by means of forceps introduced through a bronchofiberscope and continuous monitoring of the CO_2 wave form is performed using a CO_2 monitor. This method has been developed to evaluate regional gas exchange and is applied in clinical disorders such as lung cancer and pulmonary thromboembolism. In patients with lung cancer, two different findings were obtained depending on the presence or absence of lober dead space ventilation. Lobes with dead space ventilation showed decrease of end-tidal and mean alveolar PCO_2, flattened CO_2 wave form and a high CO_2 pressure peak at the early inspiratory phase, when compared to those of normal lobes. On the other hand, in lobes without dead space ventilation, there was no difference in terms of CO_2 pressure values and CO_2 wave form between all lobes, the trachea and the site of lung cancer. In a case of pulmonary thromboembolism, the lobe with blood flow disturbances had decreased end-tidal and mean alveolar PCO_2 and flattened CO_2 wave form with a peak. Treatment of pulmonary thromboembolism resulted in improvement of these abnormalities. These results demonstrate that the FBC method, which can be done easily and repeatedly, to evaluate the blood flow under dynamic conditions may be useful for the diagnosis and localization of blood flow disturbances and in evaluating the efficacy of treatment.

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Although rarely considered in series of lower airway foreign bodies, can cause chronic cough, hemoptysis and even death in some cases. Eighty cases of endobronchial foreign bodies, treated in 20 related centers were reviewed. The averaged age was 35.5 years, ranged from 2 months to 93 years with a peak number seen in 1∿4 years aged group and 60∿79 years old group. Clinical symptoms varied from none to severe respiratory distress, cerebral disturbance, and even death on arrival. Atelectasis of one lobe or one lung was a common sign appearing on chest X-ray in children, and normal findings or the presence of foreign body (FB) were seen in elderly patients. Concerning the type of FBs food totaled 50%, dental crowns 16%, and toys 11%. Approximately one-third of all patients visited the medical centers within an hour, while 14% of aspired FBs were detected only after 12 weeks due to patients' delay. Complication rate increased in relation to delay of visiting the medical centers and a late diagnosis. Regarding the treatment, one-half of the FBs were removed by flexible bronchoscope, with a median procedure time of 35 minutes. Ventilating bronchofiberscope was used in 19%, mostly in children. Eleven cases needed surgical resection, indicated to secondary pulmonary abscesses in 3 cases, empyema in one and hemoptysis or other morbid situations in 7 cases. Consequently, early observation and treatment by flexible bronchoscopy in cases of bronchial foreign bodies was of great value.

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During the treatment of lung disease, especially lung cancer, acute diffuse lung shadows, which are difficult to diagnose, sometimes appear. The patient's conditions frequently take a turn for the worse. To diagnose these shadows, a bronchoscopic approach was planned as follows. Under fluoroscopy, the shadows were brushed and biopsied via the bronchoscope. Brushing specimens were smeared and either dried or fixed in 95% ethanol. Ethanol fixed preparations were stained by Papanicolaou, PAS, Grocott, and Toluidine blue stain. Dried smears were stained by Gram, May-Giemsa, and Ziehl-Neelsen stain. Brushing specimens were also cultured by agar. Biopsy specimens were stained hematoxylin-eosin, PAS, Alcian-blue, Elastica-Masson, Grocott stain. Lymphocyte stimulation tests (LST) and enzyme-linked immunosorbent assay for viral infection were examined in some cases. In 13 of 15 patients, these examinations were useful in diagnosing lung shadows.

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We have reviewed 16 patients with inhalation injury who were admitted to Saga Medical School from January of 1987 through December of 1992. There was correlation between burn severity and mortality. In point of the anatomical division of inhalation injury, no patients with upper airway and/or major airway injury died. The patients with severe injury limited to upper airway underwent endotracheal intubation and then the final outcomes were good. But all four patients with parenchymal injury died. In 2 of 4 cases with parenchymal injury, fatal pulmonary complication occurred for several days after the injury. Fiberoptic bronchoscopy is useful for diagnosing inhalation injury and decide the indication of endotracheal intubation. But it is difficult to predict parenchymal injury.

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A 73-year-old man was admitted to our hospital complaining of hemosputum. A chest X-ray revealed a cavity formation in a nodular shadow in the right upper lobe and stenosis of the right main bronchus. A diagnosis of squamous cell carcinoma was based on transbronchial tumor biopsy by bronchofiberscopy. After bronchial artery infusion therapy, the cavity increased, and the inner surface of cavity was observed through right upper lobe bronchus by a bronchofiberscope. There have been few reports about the cavity of primary lung cancer observed bronchofiberscopically. Therefore, this case may provide important information on the mechanism of cavity formation in primary lung cancer.

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A 59-year-old male presented with wheezing and dyspnea on exertion. Chest tomography and chest CT revealed an endotracheal mass lesion of 2 cm in diameter, originating from the lower third of the trachea. Bronchoscopy showed a polypoid tumor arising from the left posterior wall of the trachea with a smooth surface and partially hyperemic mucosa, occupying approximately 80% of the tracheal lumen. Subsequently, bronchofiberscopic polypectomy was performed by electrocautery using a polypectomy snare. Postoperatively the patient had immediate and markedly improved respiration and there was no further wheezing. Microscopically, the tumor was diagnosed as a tracheal neurilemmoma. The lowest four tracheal rings were resected, together with the endotracheal tumor, followed by end-to-end anastomosis. The postoperative course was uneventful and the patient is well at the time of writing.

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Pulmonary aneurysm resulting from arterial erosion in pulmonary tuberculosis is rare. This disease is known as Rasmussen's aneurysm, occuring in association with chronic tuberculous cavities. We reported another form of tuberculous pulmonary artery aneurysm. A 74-year-old female was admitted to our hospital because of hemoptysis and dyspnea. Two years before admission tuberculosis had been diagnosed, but she had not received sufficient treatment. She had nodulaly infiltrative tuberculosis affecting mainly the left upper lobe. Bronchoscopic examination revealed the tumor in the left upper lobe bronchus. During examination the tumor ruptured. Causing sudden massive bleeding and she expired immediately. Autopsy findings showed rupture of the left pulmonary artery aneurysm to the left upper lobe bronchus. Microscopically, tuberculosis had eroded the bronchial and arterial wall.

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Newly developed catheter-type radial scanning ultrasonographic probes were introduced into the bronchial lumen via the biopsy/suction channel of a fiberoptic bronchoscope in patients with bronchial tuberculosis. Enlarged bronchial arteries inside and outside of the cartilage layer, distorted or fragmented bronchial cartilage, eccentric thickening of the bronchial wall, secretion retention distal to sites of stenosis, and enlarged lymph nodes adjacent to the bronchial wall with calcification were among the pathologic changes observed. Transluminal ultrasonography is also useful in preoperative evaluation of patients scheduled to undergo bronchoplasty due to bronchial tuberculosis.

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A case of tracheobronchomegaly with air trapping due to obstruction of the left main bronchus discovered on CT at maximal expiration is reported. The patient declined bronchofiberscopy and bronchography, so the authors performed three-dimensional visualization of the morphological changes of the trachea and main bronchi at inspiration and expiration in this case.

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Eleven cases of postoperative recurrent lung carcinoma were detected by bronchofiberscopy in the past 6 years. Of these, 9 were male, and 2 were female with an average age of 68.5. Eight were squamous cell carcinomas, and three were adenocarcinomas. The initial operations consisted of 1 pneumonectomy and 8 lobectomies, 2 partial resections. The postoperative stages were Stage I in 5, Stage IIIA in 3, and 1 each in Stage II, IIIB, IV. The reason why they underwent bronchofiberscpy were dyspnea, hemosputum, abnormal shadow on chest x-ray examination, elevation of serum tumor markers and examination of the bronchial stump. After diagnosis of recurrent lung carcinoma, 8 cases died within 10 months. Nd-YAG Laser was utilized in 8 cases, 6 of which were emergency procedures because of airway stenosis. Two cases are alive at over one year, one treated with only Nd-YAG laser, the other treated with laser combined with chemotherapy. Other cases were treated with re-operation in 2, and irradiation in 1. A re-operated case survived over one year and an irradiation case is alive at 22 months. Because of decreased postoperative respiratory function, and the central location of recurrence, treatment is difficult, therefore multidisciplinary therapy is necessary.

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We reported an extremely rare case of small cell carcinoma of thymus with tracheal invasion. A 50-year-old female suffering a gradual increase in hoarseness was admitted to our hospital for evaluation of an abnormal mass on chest X-ray film which was suspected to be a malignant mediastinal tumor. CT showed a mass located to the right of the trachea from the superoanterior to the middle mediastinum, expanding and invading into surrounding organs. Fiberoptic bronchoscopy demonstrated extensive tumor invasion to the tracheal wall from the right lateral portion to the membranous portion. Microscopic examination of specimens obtained by echoguided percutaneous aspiration biopsy revealed small cell carcinoma. Because the tumor had already considerably progressed, to T3N2M1 according to the TNM classification of thymic epithelial tumor by Masaoka et al, the patient was treated with combination chemotherapy consisting of cisplatin, ifosfamide and etoposide. Partial response was observed and the serum level of NSE, which had been high on admission, decreased to normal.

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Two cases with broncholithiasis are presented. Case 1, a 40-year-old male, presented with a chief complaint of hemoptysis. Chest roentgenogram revealed an infiltrative shadow in the right middle lung field. CT scan showed a small calcified nodule, 8×5mm, at the orifice of the lateral segment of the right middle lobe with segmental atelectasis of S^4 distal to the obstructing broncholith. Fiberoptic bronchoscopy disclosed a broncholith obstructing the lateral segment of the right middle lobe (r-B^4). Through a bronchoscope the stone was partly removed. The stone was mainly composed of calcium carbonate. Case 2, a 65-year-old female, presented with chest X-ray abnormality showing consolidation consistent with segmental atelectasis of S^8. Bronchoscopy revealed a polypoid lesion obstructing the orifice of right B^8. Though the intraluminal stone was not visualized bronchoscopically, CT demonstrated calcified nodule in the right hilum consistent with the orifice of right B^8. The cause of broncholithiasis in our patients was considered to be calcified hilar lymph nodes, because of the finding of broncholith with irregular surface, which had apparently eroded into the bronchial wall in case 1 and broncholith beneath the bronchial mucosa detected by CT in case 2, and several calcified nodules in the hilar and mediastinal regions in both cases.

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A 36-year-old woman was admitted to our hospital with non-productive cough after improvement of mycoplasma pneumonia. Her chest roentgenogram showed almost no pulmonary infiltrates but examination of her sputum revealed many eosinophils. The pulmonary function test results, including carbon dioxide diffusion capacity were normal and bronchodilator treatment did not significantly improve either FEV_<1.0> or FVC. Therefore it was thought that eosinophilic bronchitis without asthma was associated with mycoplasma pneumonia. According to the treatment regimen for atopic cough, a histamine H_1-blocker, azelastin, was prescribed and her dry cough improved. We concluded that to evaluate bronchial lesions is useful for the successful treatment of severe cough associated with mycoplasma pneumonia.

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An 81-year-old male who had received total gastrectomy for gastric cancer in 1986, visited our hospital because of productive cough in August 1993. Chest X-ray film revealed no abnormal shadows. Bronchofiberscopy showed a granular protruding lesion at the bifurcation between 1 B^<1+2+3> and B^<4+5>. Bronchoscopic and histological findings indicated early stage squamous cell carcinoma. Nd-YAG laser therapy was performed because of his age and respiratory dysfunction. Additional radiation therapy was performed, because Nd-YAG laser to the tumor margin was incomplete. After treatment, no cancer cells were identified. The patient's condition is satisfactory without any complaints 5 months after treatment.

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A 74-year-old female was found to have atelectasis of the left lung. When she consulted a practitioner suffering from dyspnea and she was admitted to our hospital. A tumor almost completely obstructing the left main bronchus was found by bronchoscopy and bronchial carcinoid was diagnosed by the biopsy. Nd-YAG laser was performed to improve the dyspnea. The dyspnea subsided (Hugh-Jones : V to II) after the laser treatment (Total 6439J). It was clear that primary bronchial carcinoid was in the left upper division. Left pneumonectomy was performed because of invasion to the left B^6 and the bifurcation between upper and lower lobe bronchi. In this case, even though it took about 50 days from the onset of atelectasis to laser treatment, the volume of left lung recovered. It is important to perform the laser treatment before pneumonectomy and to attempt the bronchoplasty, if the volume of the lung can be restored.

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A 77-year-old man presented with bloody sputum underwent bronchofiberscopy at a local clinic. The examination revealed an irregular endotracheal tumor, 2.0×1.5cm in size, in the membranous portion of the pre-carinal region. Biopsy revealed squamous cell carcinoma, and he was admitted to our department for surgical resection. A chest CT demonstrated no extratracheal tumor invasion and no mediastinal lymph node metastasis. Systemic examinations also showed no evidence of any distant metastasis. He had a medical history of myocardial infarctions 10 and 6 years ago, and coronary angiography confirmed the 3 vessel disease. Surgical treatment was not indicated because of the high cardiac risk, so we employed Nd-YAG laser irradiation with radiotherapy. Five sessions of trans-bronchofiberscopic laser irradiation were performed, each at 30W, continuous wave, through the non-contact type probe, for a total energy delivery of 34, 667J, with subsequent radiotherapy of 60Gy administered to the mediastinum around the carina. Now, 3 years after the treatment, there is no evidence of any tumor recurrence or metastasis.

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