We reviewed the medical records of 135 patients with hemoptysis to investigate the indications for fiberoptic bronchoscopy. There were 48 patients with findings related to hemoptysis on chest roentgenograms, and 87 patients without any related findings. Lung cancer was diagnosed in 33.3% of the 48 patients with related findings on chest roentgenograms, and 2.3% in the 87 patients without related findings. All 18 patients with lung cancer were males over 40 years old with significant smoking history (≧20 pack-years). Among the 18 cases there were 4 patients with negative sputum cytology. In 2 out of the 18 patients lung cancer was detected only by fiberoptic bronchoscopy. It was not possible to detect all lung cancer by only chest roentgenograms and sputum cytology in patients with hemoptysis. We conclude that the following patients should be examined using fiberoptic bronchoscopy if they complain of hemoptysis ; (1) all patients with abnormal findings on chest roentgenograms and (2) patients over 40 years old with significant smoking history even without abnormal findings on chest roentgenograms.

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Endoscopically and histologically we assessed a new tracheal anastomotic technique by a mechanical stapling device. A section of cervical trachea 5 rings in length measuring between 2.4cm and 3.5cm was excised and anastomosis was performed with three mechanical anastomotic devices in group A (n=7), and resorbable 4-0 Polysorb in group B (n=4). Three linear anastomotic devices were placed outside the tracheal wall and three backing sutures were made by three 2-0 silkwormgut for end-to end tracheal anastomosis. Postoperative bronchoscopic evaluation of the mechanically anastomosed site in group A did not detect any stenosis and the same result were seen in group B. All animals survived throught the experimental period of eight weeks. On bronchoscopic examination of the anastomotic sites, All 7 dogs in group A showed circumferential anastomotic stenosis due to granulation at the end of the experimental period. However, we could not detect anastomotic stenosis in group B. Histological examination confirmed inflammatory stenosis in one of the sacrificed animals in group A. This new mechanical tracheal anastomotic technique should be improved with regard to postoperative stenosis.

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A 70-year-old man with right partial hemiplegia was admitted to our hospital because of productive cough. Sputum cytology results were suspicious. On admission chest X-ray film showed no tumor shadow. Chest CT scans showed only thickening of the walls of the right main and upper lobe bronchi. Bronchofiberscopic examination revealed small nodular tumors at the orifice of the right upper lobe bronchus, which were diagnosed as squamous cell carcinoma by cytological examinations. Extensive superficial cancer infiltration characterized by an irregular mucosal surface and disappearance of the mucosal folds was also detected. Two courses of chemotherapy (cis-platin+vindesine) and chest irradiation (50Gy) were done simultaneously. After treatment, no visible tumor was found and no cancer cells were obtained by transbronchial brushing. The case suggested that combined modality treatment could be effective in inoperable squamous cell carcinoma of the hilar type.

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A 58-year-old male was referred to the Hokushin General Hospital because a routine chest X-ray showed abnormal findings. Bronchoscopy showed a tumor occluding the right upper lobe bronchus and an invasive lesion in the right lower portion of the trachea. The pathological examination revealed squamous cell carcinoma. The lesion in the lower portion of the trachea was presumed to be a metastasis of the primary tumor in the right upper lobe bronchus. After the primary tumor and the metastatic lesion were reduced by bronchial artery infusion of cisplatin, the patient was referred to our hospital for surgery. A right upper lobectomy with tracheobronchial wedge resection between the right lower end of the trachea and the proximal end of the truncus intermedius was performed. The postoperative course was uneventful and there was no stenosis of the anastomotic site. It was reported that an extensive bronchial wedge resection might cause stenosis or bending of the anastomosis. However, in our case, we succeeded in making a large orifice for the anastomosis because one area of the anastomosis included the lower portion of the trachea. It is of interest that malignant cells were identified pathologically only in the lymph nodes around the upper lobe bronchus after the bronchial artery infusion.

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A 42-year-old woman was admitted to our institution with tuberculosis. Atelectasis of the left upper lobe was pointed out during treatment, and bronchofiberscopy revealed the tuberculous stenosis of the left main bronchus and obstruction of the left upper bronchus. Four months after negative culture of tubercle bacilli, left upper sleeve lobectomy was performed with an anastomosis between the left main bronchus at the second cartilage ring from the carina and the left lower bronchus with absorbable monofilament sutures. Bronchofiberscopy after 6 months showed a successful suture line without an obstructive lesion. Bronchoplasty is a useful operative procedure for localized tuberculous bronchial obstructive lesion.

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We report a patient with pulmonary aspergilloma in which a fungus ball was observed by bronchoscopy. An antimicrobial agent was infused into the chest cavity through an indwelling transcutaneous tube. The patient was an 83-year-old man who presented with hemoptysis. The chest X-ray film showed tumor shadows in the left lung apex and on bronchoscopy yellow-white protruding lesions occluded B^3 and the lingular division at the entrance to B^<1+2>. The biopsy specimen contained aspergillus hyphae and fungus bodies, confirming the diagnosis of aspergilloma. Based on the patient's wishes medical treatment was pursued. A combination of miconazole (30mg/day) and lidocaine (40mg/day) was infused for 97 consecutive days through the indwelling transcutaneous tube. Simultaneously, miconazole (200mg) was given intravenously twice a day. A follow-up bronchoscopy on day 119 disclosed a decrease in the size of the fungus ball, of the which 30mg miconazole was infused through the bronchoscope. The transcutaneous tube was removed 5 months after the treatment started. The treatment was considered effective since hemoptysis stopped and tumor shadows decreased on X-ray films.

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Two cases of pneumocystis carinii pneumonia (PCP) associated with immunosuppressed status are presented. They showed rapid progressive symptoms and serious hypoxemia. Transbronchial lung biopsy and bronchoalveolar lavage were very useful for the early diagnosis of PCP. They were treated with administration of trimethoprim-sulfamethoxazole or pentamidine isethionate and a high dose of corticosteroid. Clinical and radiological improvement was obtained by the administration of high dosage corticosteroid as an adjunctive therapy.

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A 54-year-old male admitted to our hospital with complaints of dry cough and general malaise. He drank heavily and was diagnosed a having diabetes mellitus on admission. Chest X-ray showed bilateral multiple infiltration. Bronchofiberscopy was performed after admission and Nocardia brasiliensis was isolated from tracheal secretions, bronchial washings and bronchoalveolar lavage. Pulmonary nocardiosis was diagnosed. After administration of Trimethoprim-Sulfamethoxazole (TMP-SMZ), symptoms and bilateral multiple infiltration shadows on X-ray improved. Leukopenia caused cessation of treatment with TMP-SMZ. Minocycline obtained clinical improvement. Nocardia is sometimes detected from sputum of healthy persons, and bronchofiberscopy in this case was useful for the early diagnosis of pulmonary nocardiosis. It is necessary to pay attention to adverse reactions such as leukopenia during the course of the therapy. It is rare for N. brasiliensis to be detected in nocardiosis.

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A case of cytomegalovirus infection in a 20-year-old male who received bone marrow transplantation (BMT) after a diagnosis of aplasticanemia. One month after BMT, abrupt onset of dyspnea developed and chest X-ray films disclosed bilateral diffuse reticular shadows in the lower lung fields. A diagnosis of interstitial pneumonia secondary to GVHD was made and the patient was given prednisolone pulse theraphy with symptomatic improvement. Dyspnea recurred in addition to fever appear with bilateral diffuse granular shadows mainly in the lower lung field on a chest X-ray study after 10 days. Pneumonia due to Cytomegalovirus (CMV) or Pneumocystis carinii was considered likely. A diagnosis of cytomegalovirus pneumonia secondary to immunodeficiency was established beared on the detection of CMV in BALF using PCR and positive CMV antigen (C7-HRP) in the serum.

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A 63-year-old man was admitted complaining of fever and dyspnea. A chest X-ray film showed bilateral diffuse abnormal shadows and he had severe hypoxemia. Severe pneumonia was diagnosed and was treated with FMOX, DOXY, EM and FLCZ. Because the diffuse shadow worsened, a fiberoptic bronchoscopy was performed. BAL fluid findings showed an increased number of eosinophils. Examination of the TBLB specimen disclosed diffuse alveolar damage with organization. Steroid pulse therapy was effective, the pulmonary symptoms improved markedly and the chest X-ray abnormalities disappeared. Serological studies revealed an elevated titer of serum antibodies to influenza virus type A. In spite of steroid pulse therapy, acute interstitial pneumonia associated with unknown etiologies has a high mortality. Some patients with DAD may benefit from steroids. The present case illustrated the effectiveness of early steroid therapy.

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A 46-year-old female visited to our hospital with severe dry cough. Her chest rogntgenogram showed bilateral basal interstitial shadows. Though her chest X-ray film showed no exacerbation, her severe cough progressively worsened. The pulmonary function test was normal and bronchodilator treatment did not significantly improve either FEV_<1.0> or FVC. Therefore, this case was considered to have chronic interstitial pneumonia complicated with atopic cough (eosinophilic bronchitis without asthma). Severe cough was not relieved with an H_1-blocker (azelastin). So she was treated with prednisolone (20mg/day). Although her chest X-ray film did not improve, the severe cough resolved rapidly. She developed muscle weakness in her legs and a high CK value during course of tapering of the steroid dose. The findings of biopsy specimens obtained from the left vastus lateralis were compatible with dermatomiositis. We concluded that to evaluate bronchial lesions is useful for the successful treatment of severe dry cough associated with collagen vascular desease such as dermatomiositis.

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A roentgenographically occult lung cancer of the right lower lobe bronchus was diagnosed bronchoscopically in a 57-year-old man. Although intraluminal radiotherapy had been planned first, he actually received right lower lobectomy with lymph node dissection. The detection of a small nodule suspected to be metastasis in the right S^6 area by chest CT was the reason for the operation. The lesion in right B^<9+10> extended longitudinally was 25mm and was intramural poorly differentiated squamous cell carcinoma. The pathology of the right S^6 lesion in the same lower lobe was also poorly differentiated squamous cell carcinoma with severe atypism. Squamous cell carcinoma within the bronchial wall extending for more than 20mm of longitudinal extention is sometimes metastatic via the lymphatics. Although this peripheral lung lesion was suspected to be multiple lung cancer, it was diagnosed as intrapulmonary metastasis for the above reason. It is necessary to examine the entire body for the existence of metastasis or multiple lesions even in the cases of lung cancer limited to within the bronchial wall.

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A 46-year-old man with liver cirrhosis, who had been operated upon for hepatocellular carcinoma in 1992, developed dyspnea on exertion in April, 1994. He was admitted to our hospital because of atelectasis of the left lower lobe. Bronchofiberscopic examination revealed a large polypoid tumor completely obstructing the orifice of the left main bronchus, and transbronchial biopsy confirmed a diagnosis of adenoid cystic carcinoma. Chest CT showed that the tumor obstructed the left main bronchus. Bronchofiberscopic treatment was preferred because of severe liver dysfunction. Several sessions of bronchofiberscopic Nd-YAG laser and intratumoral injection of ethanol were performed. The obstruction was improved after the spontaneous expectoration of the degenerated and necrotic tissue, and the tumor obstructing the left main bronchus was successfully diminished. During treatment, cough, fever and slight impairment of liver function appeared as the complications of bronchofiberscopic intratumoral injection. We reported a case in which bronchofiberscopic treatment was safe and effective to improve the airway obstruction and diminish the tumor in a patient with a severely cirrhotic liver.

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The patient was a 19-year-old man who received antituberculous drugs for pulmonary tuberculosis from August 1993. One year later, the patient developed dyspnea, and chest X-ray showed complete atelectasis of the left lung secondary to bronchial tuberculosis diagnosed by bronchial biopsy. Bronchofiberscopy after admission to our hospital showed reddening and edema of the mucosa of the left main bronchus and occlusion three cartilage rings distal to the tracheal carina. We first used a 5Fr Fogarty balloon catheter to dilatate the site of occlusion under bronchoscopic guidance. The left main bronchus was successfully dilatated to a diameter of about 5 mm and the left lower lobe was re-expanded. 3D-CT revealed occlusion of the left upper lobe bronchus and patency of the lower lobe bronchus. One week later, the stenotic site was dilatated to a diameter of about 8 mm using a 5Fr PTCA catheter, and 2 weeks later, dilatated to a diameter of about 1 cm using a 9Fr Sengstaken-Blakemore tube with the balloon left in place for 1 day. 3D-CT showed the left main bronchus to have a diameter of about 8 mm. In this case, a stepwise balloon dilatation method was effective in relieving airway occlusion secondary to bronchial tuberculosis and 3D-CT was useful for evaluating the extent of stenosis.

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A 72-year-old male was admitted with asthma-like cough and sputum. Atelectasis of the right lower lobe was recognized roentgenologically and suspected lung cancer. Bronchofiberscopic examination under local anesthesia revealed granulations around the bronchial wall and a foreign body obstructing the right truncus intermedius were observed. The foreign body was successfully removed by bigger, rigid forceps inserted into the broncus through a rigid bronchoscope under general anesthesia. With the flexible bronchofiberscope, we could not capture the foreign body with biopsy forceps. The foreign body was a plant seed. After the foreign body was removed, the chest X-ray film showed improvement of the atelectasis and the granulation was observed to decrease by bronchofiberscopy. The patient did not remember when the body entered his bronchus.

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A new spraying device has been developed for topical anesthesia for fiberoptic bronchoscopy. The device is a modified Jackson's spray ; i.e. distally a fine teflon catheter is connected to the tip of the Jackson's spray, proximally oxygen at 5 atm. is obtained by the air gun. The catheter, 1mm in an outer diameter and about 1m in length can be easily inserted into the forceps channel of the bronchofiberscope. During bronchoscopy, fine lidocaine mist can be sprayed from the tip of the catheter whenever greater anesthesia is needed.

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