Although the use of supplemental oxygen has been recommended to prevent hypoxemia during bronchoscopic procedures, few reports have suggested covering how much oxygen shoud be given. To determine the optimal quantity of supplemental oxygen to keep transcutaneous oxygen saturations (SpO_2) more than 90% during bronchoscopic procedures, we measured arterial blood gases before bronchoscopy and divided patients into two groups : those with arterial oxygen pressure (PaO_2) greater than or equal to 70Torr (group A) and those with PaO_2 less than 70Torr (group B). Patients in group A breathed room air or were given 2 l/min or 4 l/min supplemental oxygen via nasal catheter. Patients in group B were given either 2 l/min or 4 l/min supplemental oxygen. Transcutaneous oxygen saturations were measured and electrocardiograms were recorded before and after bronchoscopic procedures. Transcutaneous oxygen saturations decreased in all groups during bronchoscopic procedures, but they decreased in those who received 4 l/min supplemental oxygen less than those who received 2 l/min supplemental oxygen. Transcutaneous oxygen saturations were less than 90% in nearly all patients in group A who breathed room air and those of group B who received 2 l/min supplemental oxygen, especially after transbronchial lung biopsy or bronchoalveolar lavage. Transcutaneous oxygen saturations were more than 90% in those of group A who received 2 l/min supplemental oxygen and those of group B who received 4 l/min supplemental oxygen during bronchoscopic procedures, and arterial carbon dioxide pressure (PaCO_2) were unchanged. These results suggest that patients with prebronchoscopy PaO_2 greater than or equal to 70 Torr should receive 2 l/min supplmental oxygen, and patients with PaO_2 less than 70 Torr should receive 4 l/min supplemental oxygen during transbronchial lung biopsy or bronchoalveolar lavage.

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The diagnosis of fat embolism syndrome (FES) is often difficult, despite the massive volume of literature devoted to this diagnostic problem. Identification and early treatment of this clinical entity have been hampered by the lack of "gold standard" objective test for diagnosis. Recently, the presence of lipid-laden cells in fluid obtained by bronchoalveolar lavage (BAL) has been proposed as a specific tool for FES diagnosis in trauma patients. Our purpose was to establish the specificity of lipid staining of bronchoalveolar cells for diagnosing FES. We performed BAL using a 4.5mm diameter bronchofiberscopy wedged gently into either a lingular or right middle lobe subsegmental bronchus, and instilled sterile normal saline in 20ml aliquots (total 100ml) and immediately aspirated the fluid manually with a syringe. We counted the total cells contained in uncentrifuged specimens of the lavage fluid using a hemocytometer, then in centrifuged (1500rpm, 5 min.) fluid, and subsequently performed differential cell counts on the preparation by staining with Wright-Giemsa stain. The proportion of lipid-laden cells containing red or red-brown fat droplets was calculated after examination of at least 200 cells on a Sudan-III slide. We compared lipid-laden cell counts among patients with definitively diagnosed lung diseases. In 12 out of 113 patients, lipid-laden cells accounted for less than 5% of the total. The calculated specificity, assuming that a negative finding was defined as ≦5% lipid-laden cells, was 11.1%, the positive predictive value was 5.0%, and the negative predictive value was 100%. Lipid-laden cells were present in not only FES but also other lung diseases, and the percentage of lipid-laden cells showed no significant differences among 11 definitively diagnosed cases of lung diseases. These results suggested that the presence of lipid-laden cells stained by sudan-III is not a useful indicator for diagnosing FES. However, we hypothesize that the lipids in cells of FES patients are exogenous lipids from bone marrow or soft tissue, which should be distinguishable from endogenous lipids appearing in other lung diseases. We propose the further study of the lipids in alveolar cells using other staining methods, such as Nile blue staining to identify free fatty acids and distinguish them from neutral fat, or biochemical analysis to evaluate the pathogenesis of FES.

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In the 11 cases of endobronchial tuberculosis in this series predominance in women and nonsmokers was recognized. In our cases, sputum smears were positive in only 2 cases on Ziehl-Neelsen staining. On bronchial brushing 7 cases of 11 were positive by bronchial brushing. The remainder 2 were diagnosed pathologically by bronchial biopsy specimens. Generally bronchial tuberculosis presents a productive cough, wheezing, and other. However, asymptomatic cases are not rare and it is more frequently seen in the elderly patients. On chest X-ray, obstructive pneumonia and infiltration shadow are observed and middle lobe syndrome is relatively indicative. Bronchofiberscopy is very important for diagnosis and follow up. Combination of INH, RFP, SM or EB is the standard therapeutic regimen and it is usually effective. However, some cases deteriorate and the bronchus develops scar formation. Sometimes progressing to bronchial stenosis and obstruction. For prevention these developments, early diagnosis and initial therapy is important.

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We reported two cases of pulmonary squamous cell carconoma, in which lesions of the cavity were suspected by chest X-ray and computed tomography and in whom the cavity could be directly visualized by bronchofiberscopy. These cases are reported with a discription of the mechanism of cavity formation and discussion of the literature. The first case was a 60-year-old male. Giant bullae were reveald in the bilateral upper lung fields, and the patient was diagnosed as having pulmonary squamous cell carcinoma by sputum cytology. The cavity was directly visualized from the left upper lobe bronchus by bronchofiberscopy. The second case was a 63-year-old male who had undergone detailed examinations for an abnormal shadow of the right upper lung field. The cavity was directly visualized from the right upper lobe bronchus by bronchofiberscopy. Examination of the sputum detected squamos cell carcinoma. Autopsy observation revealed that direct invasion with wide-ranging necrosis to the cavity wall and the bronchus in the both cases. In both cases the carcinoma was considered to have originated from the bulla wall, invaded the surrounding tissue, and developed necrosis, leading to communication with the bronchus.

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Gianturco self-expandable metallic stents (EMS) were used in three patients who developed severe dyspnea because of tumor strictures in the trachea or bilateral main bronchi. Patients with untreated primary small cell carcinoma in the lung already showed respiratory failure at the time of hospitalization. One of them had experienced respiratory arrest because of airway obstruction one day before hospitalization. As they were in danger of asphyxiation during anticancer therapy, maintenance of a patent airway should be a top priority. Dyspnea was markedly improved in all cases after placement of the EMS. In all three patients, the maintenance of patency of the airway by the use of EMS made it possible for the patients to receive chemotherapy and radiotherapy safely. The duration of EMS placement was 8 to 25 days. The stent migrated spontaneously in two patients but there were no stent-related complications. With safe and complete anti-tumor therapy enabled by EMS placement, the tumor was reduced in all patients. The use of EMS is expected to prevent airway obstruction and to allow complete by effective anti-tumor therapy. It should be useful as supportive therapy in the acute stage of cancer disease.

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A 60-year-old man was admitted to our hospital for evaluation of a right lower lung tumor shadow. Stage I squamous cell carcinoma of the lung was diagnosed and right lower lobectomy was performed. Nine months after surgery, bloodysputum appeared. No abnormal shadow was detected on chest X-ray, but bronchoscopic findings showed a tumor at the surgical margin and multiple polypoid lesions in the trachea and right main bronchus. All biopsied specimens revealed squamous cell carcinoma, therefore this case was thought to be endotracheobronchial metastasis following absolutely curative operation of lung cancer.

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A 26-year-old man suffered from tuberculous bronchial stenosis of the left main and left upper lobe bronchi accompanied by left upper lobe atelectasis. The first operation was planned to include left upper sleeve lobectomy with anastomosis of the trachea and the left lower bronchus. First, the left main bronchus was incised, but since the lumen was stenotic, the incision was extended anterior to the carinal cartilage and 2 rings of the tracheal cartilage laterally. The operative procedure resulted in one-stoma-type carinoplasty. After the operation, the endtracheal tube was removed, but the patient could not breath because of compression of the trachea immediately above the anastomotic site. Reoperation was performed on the 9th postoperative day, since the stenotic state had not improved. Median sternotomy was performed. The lower portion of the trachea was retracted to the left, and the anastomotic site was bent and inserted under the aortic arch. The left lower lobectomy was performed, and the left lower bronchus was closed with the remnant about 5mm from the anastomotic site. The carina and the stump of the left lower lobe bronchus were wrapped by a pedicled omental flap. Immediately after the operation, the mucosa of the preserved left lower lobe bronchus appeared dark red, but gradually became white. Two months after the second operation, the mucosa seemed normal.

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A 13-year-old woman was admitted for the examination of abnormal shadows on chest X-ray. Chest roentgenogram and CT showed hyperlucency of the right S^3 and a cavitary shadow with a niveau in the right hilum. This shadow was considered to be due to mucoid impaction, because it was weighted by MRI-T2 images. Bronchofiberscopy and bronchography revealed defects of right B^3, and pulmonary arteriography revealed reduction of blood flow to right S^3. Right upper lobectomy was performed on a diagnosis of congenital bronchial atresia. Histological examination of the resected lung showed emphysematous change of right S^3 and the dilated bronchus containing mucoid impaction, which did not communicate to the central airway. The literature on congenital bronchial atresia (55 cases, including our case, reported in Japan) was reviewed and discussed.

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We describe a case of a 72-year-old female who was referred to our clinic for relapsing right middle lobe pneumonia. Cystic bronchiectasis and organizing pneumonia were diagnosed. Nineteen months later, the chest X-ray film showed an increase in the size of infiltrative shadows. Chest CT demonstrated a well-defined cystic mass shadow in the right S^5 and consolidated shadows in the right lower lobe. Bronchofiberscopy revealed a mucus plug completely occluding the right B^5a. Transbronchial lung biopsy specimens obtained from the right lower lobe showed mucus-producing bronchioloalveolar carcinoma. Pathological findings of biopsy specimens from the cystic mass wall were consistent with mucinous cystadenocarcinoma. These clinico-pathological features emphasized the importance of clarifying the developmental process of mucinous cystadenocarcinoma.

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A 53-year-old male patient with Sjogren's syndrome was admitted because of pyrexia and dry cough. Although he was afebrile after treatment with antibiotics, chest X-ray film revealed consolidation of the right middle lobe. Bronchofiberscopic findings revealed a nodular lesion in the right middle lobe bronchus. Biopsy yielded a diagnosis of angiocentric immunoproliferative lesions (grade I). This entity was described as lymphomatoid granulomatosis in order to convey its histologic features. Pulmonary involvement in Sjogren's syndrome includes lymphoproliferative disorders such as lymphoid interstitial pneumonia, pseudolymphoma, and malignant lymphoma, however, to our knowledge this was a case of endobronchial lymphoproliferative lesion in Sjogren's syndrome.

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A-32-year-old man was admitted to our hospital because of a one month history of high fever. CT of the chest revealed right-sided mediastinal lymphadenopathy, with patterns of node distribution and enhancement suggesting tuberculosis. Sputum was negative for tuberculosis by smear, but transbronchial needle aspiration specimen of the mediastinal lymph node was positive for tuberculosis with the polymerase chain reaction (PCR) method. On the other hand, it was negative by smear. His body temparature dropped immediately after antituberculous chemotherapy was started. 6 weeks later, specimens showed positive results on culture. We conclude that the PCR method in transbronchial needle aspiration specimens is useful for the rapid diagnosis of mediastinal lymph node tuberculosis.

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We report a case of atypical mycobacterial disease with bronchiectasis accompanied by an increase of CA19-9 in serum and bronchoalveolar lavage fluid. The patient was a 67-year-old woman who had been treated for old tuberuculosis and bronchiectasis. She was admitted to our hospital because of cough, left chest pain and mycobacterium isolated from her sputum, which was determined to be Mycobacterium avium complex by culture of sputum. Her serumCA19-9 level was markedly increased. Therefore, to clarify the site which produced CA19-9, bronchoalveolar lavage was performed. CA19-9 was markedly increased in BALF from disease the diseased lung and the level was higher than that in serum. These results suggest that CA19-9 is produced at the disease site in the lung and the increase of CA19-9 in serum derives from that site.

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Two cases of multiple endobronchial inflammatory polyps associated with expandable metallic stent (EMS), which partially regressed following long-term treatment with oral ciprofloxacin, are reported. Case 1 was a 68-year-old man with advanced lung adenocarcinoma and bilateral main bronchi stenosis and case 2 was a 74-year-old man with tracheal stenosis due to an invasive thyroid papillary adenocarcinoma. In both cases EMS were placed. Multiple inflammatory polyps appeared 4 months later in case 1 and 6 months later in case 2. Following daily treatment with 300 mg ciprofloxacin, these polyps markedly decreased within 4 months in case 1 and within 3 months in case 2. We conclude that administration of antimicrobial agents might be effective against inflammatory polyps following developing long-term placement of EMS in respiratory tract.

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We performed left upper lobectomy acompanied with broad wedge bronchial bronchoplasty in a 57-year-old male with squamous cell lung cancer that originated in the left upper division bronchus. To ensure a cancer-free surgical stump, four-fifths of the circumference of the bronchus was resected. Suture of the anastomotic site eventually resulted in bronchial stenosis. Forty-six days after surgery, he developed lung abscess and collapse of the residual lung induced by the complete obstruction of the stenotic bronchus packed with granulation tissue and mucous plugs. Besides physiotheraphy and antibiotic treatment, two balloon-aided dilatations using high-pressure durable catheter followed by three Nd-YAG laser photocoagulation procedures (3669J) restored the patency of the bronchus, resulting in resolution of abscess and atelectasis. This combined therapeutic modality should be considered for complications due to severely stenotic bronchi after bronchoplasty.

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A 73-year-old female in whom we diagnosed multiple myeloma was admitted with chest pain and appetite loss. As her complaints persisted, esophagoscopy was performed, which showed a foreign body in the mid-thoracic esophagus. The foreign body which was immediately removed was drug packaging. Because follow-up esophagoscopy after a week showed an esophageal fistula, bronchoscopy was performed, revealing a bronchial fistula in the membranous portion of the left main bronchus. Computed tomography scan of the chest also showed the esophagobronchial fistula but no evidence of pleural effusion or severe mediastinitis. The patient was conservatively managed because of (1) age, (2) poor performance status, (3) underlying disease, (4) small fistula with no evidence of severe inflammation. Follow-up examination revealed that esophagobronchial fistula had healed spontaneously. This case indicates that esophagobronchial fistula can be drug-induced. Although management of esophagobronchial fistula is usually surgical, conservative management may be applied in patients who are unfit for surgery.

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A 70-year-old male complaining of bloody sputum was referred to our hospital. His chest roentgenogram was normal, but bronchoscopy revealed a rough surface and hyperemia at the orifice of right B^6. Bronchial wall invasion of squamous cell carcinoma was recognized histologically and a diagnosis of early hilar lung cancer (T1N0M0 Stage I) was made. Right S^6 sleeve segmentectomy with lymph node dissection (R2a) was performed to preserve the volume of the middle lobe and basal segment. His postoperative course was uneventful except for B^7 stenosis, and his lung function is increased over preoperative values. The pathological diagnosis was moderately differentiated squamous cell carcinoma T1N1M0 Stage II (#12 1 lymph node was positive). He is well, without any evidence of recurrence, one year and three months after surgery. Sleeve segmentectomy may well be considered for early hilar lung cancer, as in early peripheral lung cancer, in cases in which such a procedure can significantly preserve lung function.

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A 25-year-old female was admitted to our hospital with a complaint of fever. The chest X-ray film showed atelectasis of the right middle and lower lobes, but no tumor-like shadow. Chest CT scan revealed a tumor-like shadow, and a characteristic calcification in the shadow which was considered to be cartilage. The tumor was removed by right middle and lower lobectomy. The histopathologic diagnosis of the resected specimen was hamartoma.

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