The records of thoracoscopy in 7 cases of malignant pleural mesothelioma were reviewed. All of the patients had pleural effusion. Thoracoscopic procedures were done under local anesthesia. Multiple small nodules on the parietal pleura were seen in 4 patients and thoracoscopic biopsy of these nodules were diagnostic in all cases. Multiple nodules on the visceral pleura were seen in 2 cases which were thought to be at a more advanced stage. Pleural nodules were thought to be smaller than those seen in pleural carcinomatosis and more red than those seen in tuberculous pleuritis. In another patient, localized thickening of the parietal pleura which had a pale surface was seen and definitive diagnosis was achieved by biopsy of this site. This was thought to be an early stage case. In the other 2 cases fibrin network on the parietal and visceral pleura prevented thorough pleural examination and the pleural biopsy specimens were not diagnostic. Thoracoscopic procedures were performed both with the fiberoptic bronchoscope and with the rigid 27-Fr nephroscope. Comparing the fiberoptic bronchoscope with the rigid nephroscope, the latter was superior in the visual field range and the size of biopsy samples. We conclude that thoracoscopy under local anesthesia is tolerable and helpful in the diagnosis of malignant pleural mesothelioma with pleural effusion. Multiple nodules on the parietal pleura were thought to be typical findings of this disease.

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Forty-one cases of laryngotracheal stenosis were treated with silicone T-tubes. Causes of stenosis were post-intubation in 6, laryngotracheal tuberculosis in 3, complications after tracheoplasty in 2, relapsing polychondritis in 2, burns in 1, and malignant tumor invasion in 27 (14 thyroid cancers, 6 esophageal cancers, 5 lung cancers, and 2 tracheal cancers). Lesions of 5 patients with post-intubation stenosis and one patient with anastomotic stenosis after tracheoplasty healed with treatment by only T-tubes, within one year. In a patient with tuberculosis and the one with burns, their stenotic lesions were repaired by stenting only, for 4 to 7 years. In the other two patients with tuberculosis, T-tubes could not be removed due to malacia or granulation, despite insertion for 2 to 8 years. T-tubes applied in two cases with relapsing polychondritis improved the quality of life of the subjects by providing satisfactory airway patency. T-tubes placed into stenotic lesions, due to malignant tumor invasion, also relieved those patients from dyspnea and improved their quality of life immediately after insertion.

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Fiberoptic bronchoscopy using a protected specimen brush (PSB) was done in 18 patients. Quantitative aerobic and anaerobic cultures were performed on specimens obtained by PSB. Eight of 10 PSB specimens from patients with pulmonary infection had one or more species present at≧10^3CFU/ml. Four of eight PSB specimens from patients without infection were sterile and four yielded<10^3CFU/ml of normal oropharyngeal flora. The results from this study suggest that pulmonary pathogens are generally present in concentrations of greater or equal to 10^3CFU/ml as recovered by this technique. To investigate the accuracy of endotracheal aspiration and PSB, we studied 8 mechanically ventilated patients (four with pulmonary infection, four without pulmonary infection). When comparing endotracheal aspirates with PSB, endotracheal aspirates were often contaminated with oropharyngeal flora.

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To elucidate how inflammatory lung diseases influence sputum, we studied the relationship between sialic acid (N-acetylneuraminic acid ; NANA), fucose and albumin concentration in sputum and blood examination data in 116 patients with lung diseases producing chronic sputum. Patients were classified macroscopically based on expectorated sputum into three groups : a mucoid group (30 patients), a mucopurulent group (28 patients) and a purulent group (58 patients). We measured patients' erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood cell count and serum albumin (Alb) as markers of inflammation, and serum total protein (TP) as a marker of nutrition. NANA and fucose are contained in oligosaccharide chains of airway mucous glycoproteins. NANA is also contained in serum glycoproteins, whereas fucose is virtually absent from serum glycoproteins. Therefore fucose is a marker of airway mucous glycoproteins, and NANA is a marker of both airway mucous and serum glycoproteins. Albumin is contained in serum and its exudation occurs with respiratory tract inflammation. Sputum albumin concentration significantly correlated with markers of inflammation in all patients, in the mucopurulent group, and in some patients (ESR≧30mm/hr or Alb≦3.2g/dl) in the purulent group, but none in the mucoid group. Sputum NANA concentration was not correlated with markers of inflammation. In some patients (CRP≧3mg/dl and Alb≦3.2g/dl) in three groups and some patients (Alb≦3.2g/dl) in the purulent group, higher NANA concentrations of sputum were observed in patients with lower serum total protein. Sputum fucose concentration inversely correlated with markers of inflammation in all patients and in some patients (ESR≧30mm/hr) in the purulent group ; however, significant correlation was seen in the mucoid group. The NANA/fucose ratio in sputum significantly correlated with markers of inflammation in some patients (ESR≧30mm/hr) in the purulent group and all patients, however, inverse correlation was seen in the mucoid group. The hypoproteinemia group (TP≦6.3g/dl) had a higher percentage of severely diseased patients than the normal range group (TP≧6.4g/dl). The hypoproteinemia group also had a higher detection rate of pathogens from sputum. These findings suggest that an increase in fucose concentration of mucoid sputum is a marker of inflammation in lung diseases, but not NANA nor albumin concentrations. Moreover, an increase in albumin concentration and NANA/fucose ratio and a decrease in fucose concentration of purulent sputum are markers of inflammation. An increase in NANA concentration of purulent sputum suggests severity of lung disease and continuation or exacerbation of inflammation.

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A 76-year-old man of senile dementia was found to have drunk a few cups of kerosene by his family. Several hours later, he was admitted to our hospital because of unconsciousness. On admission, he was comatose and had respiratory failure. His chest X-ray film revealed an infiltrative shadow with volume loss in the right lower lobe. Mechanical ventilation and intravenous administration of piperacillin was soon started. Several days after admission, severe pancytopenia was found. Bronchofiberscopy was done on the second day after admission and much turbid yellow-brown colored sputum was seen in the right basal bronchus, the mucosa of which was edmatous and reddish. Bronchial toilet, endoscopic bronchial washing and air flushing was performed 7 times. After these endoscopic treatments, kerosene pneumonia was completely improved and he was discharged. A review of the literature of severe kerosene pneumonia with severe hematological damage showed that it is rarely cured. This case suggests that repeated endoscopic bronchial washing is useful in the treatment of kerosene pneumonia.

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A 65-year-old woman complained of ear pain, rinorrhea, nose bleed and eye pain and was referred to our department because she suffered from cough, bloody sputum with fever and her chest roentogenogram showed multiple nodular shadows. A diagnosis of Wegener's granulomatosis was made on the basis of cytoplasmic anti neutorophil antibody and the bronchial biopsy specimen. Tracheotomy had been performed under a diagnosis of glottic granulomatosis 41 years ago. Clinically this appears to have been a case of recurrence 41 years after onset. We discussed four cases of Wegener's granulomatosis (two localized, two systemic) in our department and the findings at fiberoptic bronchoscopy. Fiberoptic bronchoscopic examinations revealed tracheobronchial abnormalities in all patients. Fiberoptic bronchoscopic examination was effective not only for diagnosis but also for long-term follow-up.

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A 21-year-old female who had been treated with phenobarbital (180mg/day) for epilepsy for one month was admitted because she had developed a cough, whole body eruption and severe liver dysfunction. Administration of phenobarbital was discontinued and eruption and liver dysfunction subsided. These symptoms relapsed, however, with peripheral eosinophilia after administration of ambroxol hydrochloride (30mg/day) and codeine phosphate (30mg/day) for the persistent cough. Analysis of bronchoalveolar lavage fluid revealed a large number of cells and eosinophils, but without abnormalities on chest roentgenography. We diagnosed drug-induced pulmonary eosinophilia for the following reasons : (1)bronchodilators were not effective ; (2)BALF analysis showed a large number of eosinophils ; (3)respiratory function tests revealed limited diffusing capacity. The symptoms subsided within a month in response to prednisolone administration (50mg/day). The lymphocyte stimulation test was clearly positive for all three drugs (phenobarbital, ambroxol hydrochloride and codeine phosphate).

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A 68-year-old man was admitted with complaints of persistant cough. Chest X-ray film showed diffuse interstitial shadows in bilateral lung fields. Bronchofiberscopy revealed a smooth-surfaced hemispherical polypoid lesion about 2mm diameter in the membranous portion of the truncus intermedius. The polypoid lesion was completely removed by a single biopsy. Histological examination showed an inflammatory polyp, and TBLB revealed interstitial pneumonia.

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A 55-year-old male was admitted because of bloody sputum. Chest X-ray and CT scans revealed stenosis and dilatation of the left lower bronchus and post-inflammatory changes in the left lower lobe. Bronchoscopic examination revealed a mucosal bridge with scarring in the left lower bronchus. He had a past history of bronchitis or pneumonia. These findings suggest that this bronchial mucosal bridge may be associated with bronchitis or pneumonia.

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We treated two patients using the Dumon stents for nonmalignant tracheobronchial stenosis. A 15-year-old female was admitted to a hospital for dyspnea following post-reconstruction stenosis of the left main bronchus. The Dumon stent was used in combination with YAG laser ablation and rigid bronchoscopy for dilation of the bronchus. A 62-year-old male was admitted for dyspnea following stenotic tuberculous tracheitis. The silicone T tube was inserted after YAG laser ablation and tracheostomy. However, since he complained of a neck discomfort, we changed it for a Dumon stent. The suggested advantages of the Dumon stent are as follows : (1) the stent cannot be destroyed, (2) the stent does not form granulation tissue, (3) the placement is stable because of its stud, (4) the stent can be removed easily after placement. However, granulation tissue developed at the distal end of the stent in the first case and dyspnea was caused in the second case due to movement of the stent caused by cough. The results suggest that the Dumon stent is not effective in eliminating symptoms of dyspnea following extensive cicatricial tracheobronchial stenosis.

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A 62-year-old man was admitted complaining of dry cough. His chest CT showed an air-density along the right posterior side of the upper trachea. All examinations demonstrated no communication with any surrounding organs. Thoracoscopic resection was performed. The lesion had to be separated from the trachea using a surgical stapler because of strong fixation. From clinical features and pathological findings it was finally diagnosed as a tracheal diverticulum with no tracheal communication.

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Two cases of relapsing polychondritis are reported. The first case was a 48-year-old female, whose chief complaint was severe dyspnea. Fiberoptic bronchoscopy revealed the disappearance of tracheal cartilage and the complete collapse of tracheal lumen on coughing. This patient died due to cerebral hemorrhage despite intensive ventilatory care with a T-tube for 1 month. The autopsy showed destruction of tracheal cartilage and the longitudinal folds in tracheal mucosa resembled esophagus. The second case was a 58-year-old male with dyspnea. Bronchoscopy showed tracheal stenosis between the vocal cord and the carina. This patient had a saddle nose and histological destruction of the auricle. A long tracheal T-tube was inserted and he has been doing well for 5 years. We conclude that the long tracheal T-tube can improve the patient's QOL by supporting tracheal patency in cases of tracheal stenosis due to relapsing polychondritis.

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Two cases of lung metastasis of colon carcinoma complicated by pleural empyema due to transbronchial biopsy were operated. One case was a 68-year-old man. The duration from the onset of empyema to the operation was long. At operation adhesion between lung and the thoracic wall was strong and his general condition was poor, so pleural drainage was performed without resection. The other was a 46-year-old female who had multiple brain metastases and a solitary lung metastasis. She received pleural irrigation and drainage on the day empyema ocurred. 10 days after, the left lower lobe was resected. In this case intrathoracic irrigation was carried out every day and the postoperative course was uneventful. Six operated cases of thoracic empyema associated with lung tumor have been reported in Japan. In most of the cases, the causes of empyema were considered to be necrosis and infection of lung tumor, resulting from chemotherapy, radiation or transbronchial lung biopsy. We consider early complete drainage of the empyema and operation within 7 to 10 days after the onset of empyema might make simplify the resection of the tumor.

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