To evaluate the influence of parasympathetic nerve innervation on airway cough sensitivity, we examined the effect of a non-selective muscarinic receptor antagonist, ipratropium bromide (IB), on cough sensitivity to inhaled capsaicin, a stimulant to C-fiber endings, in 12 patients with asthma, 14 patients with sinobronchial syndrome (SBS) and 14 normal subjects in a randomized, placebocontrolled, single blinded, cross-over manner. Progressively increasing concentrations of capsaicin solution were inhaled for 15 seconds by mouth tidal breathing at one minute intervals from a Bennett Twin nebulizer until five or more coughs were elicited, before and 30 minutes after inhalation of 40μg of IB or placebo (freon gas) through a metered-dose inhaler. The capsaicin cough threshold was defined as the lowest concentration of capsaicin solution that produced five or more coughs. The capsaicin cough threshold was significantly increased by both IB and placebo in patients with asthma and SBS but not in normal subjects. The increment of the cough threshold defined as the logarithmic value of the cough threshold after treatment divided by the initial cough threshold was significantly greater with IB than that with placebo only in patients with SBS. These results suggest that airway cogh sensitivity is augmented through parasympathetic nerve innervation in patients with SBS but not asthmatic or normal subjects.

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The effectiveness and complications of endobronchial insertion of expandable metallic stents (EMSs) were evaluated in 18 patients with tracheobronchial stenosis (6 benign, 12 malignant) who were treated between 1991 and 1997. The 6 patients with benign disease are alive 6 months to 3 years after placement of the EMS. Three patients who were treated with EMS for granulomatous stenosis of the bronchus after sleeve lobectomy required endoscopic Nd-YAG laser treatment for growth of granulations through stent wires. One of these patients required additional insertion of a covered EMS into the stenotic site. One case treated with insertion of an EMS for bronchial stenosis due to tuberculosis is alive without complications 2 years and 3 months after placement. Among the 12 patients with malignant disease who were treated with insertion of EMS, 9 died from cancer 2 days to 8 months (mean 4.5 months) after placement, and 3 are alive 2 to 4 months after placement. The disadvantage of EMS was that tumors and granulations grew through the wires of the EMS. The advantage of EMS was that it enabled smooth excretion of sputa and maintained the respiratory tract satisfactorily. There were few life-threatening complications associated with treatment. It is important that we select EMSs which expand to the greatest degree within the layer of cartilage of the bronchial wall, and that we select covered EMSs when the stenosis is caused by growth of soft tissues (malignant tumor or granulations).

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We reviewed the postoperative complications of forty-one patients (32 males, 9 females ; mean age : 61 years) who underwent tracheobronchoplasty between 1992 through 1997. Thirty-six of these patients had malignant disease. Sleeve pneumonectomy was performed in 5 patients, wedge pneumonectomy in 1 patient, sleeve lobectomy in 27 patients, wedge lobectomy in 4 patients, and tracheal or bronchial sleeve resection in 4 patients. There were no complications in the five patients with benign disease. One of the 36 patients with malignant disease experienced anastomotic complication. He had a disturbance of pulmonary venous return following lung torsion. Other complications included recurrent nerve palsy in four patients, chylothorax in one patient, acute arterial thrombosis of a lower extremity in one patient and late phase pyothorax without fistula in one patient. Two patients died within 30 days after operation. We emphasize the importance of postoperative confirmation of the position of the pulmonary artery and vein.

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Between 1960 and 1996, 1432 primary lung cancer patients underwent surgical resection in our department. Fifty two of them (3.6%) were large cell carcinomas and 43 of them underwent bronchoscopy. The age of the patients ranged from 40 to 81 years (mean age : 63.7). There were 40 men and 3 women. The pathological stage was stage I in 13 pts, stage II in 2, stage IIIA in 14 and stage IIIB in 10. The mean maximum diameter was 4.4cm. On bronchoscopy, tumor was visible in 5 patients, stenosis due to compression in 7, bleeding in 4, mucosal redness and swelling in 4, bronchitis in 4 and no abnormality in 20. Thirty patients underwent cytological diagnosis for bronchial brushing and the results were large cell carcinomas in 8, squamous cell carcinoma in 1 and adenocarcinoma in 3. In 33 patients who underwent cytological diagnosis of bronchoalveolar lavage fluid there were 14 large cell carcinomas, 1 squamous cell carcinoma and 1 adenocarcinoma. Nineteen patients underwent transbronchial biopsy and 5 of them were diagnosed as large cell carcinomas, 2 as squamous cell carcinoma and 3 as adenocarcinoma. It is difficult to diagnose large cell carcinoma of the lung preoperatively and open lung biopsy or lung biopsy by VATS is recommended to precisely determine the histological type.

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From May 1979 to November 1995 we treated 26 lung cancer lesions in 17 chromate workers. All 17 patients were men aged 44 to 76 and the period of exposure to chromium was more than 10 years (from 12 to 32 years, median : 22.9) except one case. Fourteen of 17 patients were heavy smokers (B.I.>400), and in 11 of 13 patients, detection was made by mass surverys (sputum cytology). The fiberoptic bronchoscopic appearance was superficial infiltrating type in 13 of 26 lesions, polypoid type in 4 lesions, and nodular protuberant type in 3 lesions. The other 6 lesions could be detected endoscopically. All except one small cell carcinoma, were squamous cell carcinoma. Twenty-four lesions were early stage carcinoma, that did not invade beyond the bronchial wall. All the lesions in the 5 patients with multiple lung cancer were squamous cell carcinoma. Overall 5-year survival was 88.2% and that of early stage was 100%.

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A 70-year-old man was admitted to our hospital for a precise examination of an abnormal shadow on chest X-ray film. His medical history disclosed that alcaptonuria had been diagnosed at 67 years of age when he received a right total hip replacement. He also noted that his urine would turn almost black when left standing. Four brothers had a similar condition. When he received a bronchoscopy and a right upper lobectomy, ochronosis of tracheal, bronchial and rib caltilages was noted. Although gray coloration of the air way is a typical finding, a report on bronchoscopy in a patient with alcaptonuria is rare because alcaptonuria is a rare metabolic disorder that affects about from 0.1 to 10 persons in one million persons. Because of its rarity, we reported the bronchoscopic findings of this case.

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A 79-year-old woman was admitted to the intensive care unit with severe respiratory failure. Several weeks before admission, she had received medical treatment for an asthma attack. A chest radiograph on admission revealed complete atelectasis of the left lung. Bronchoscopic examination showed a white viscous tumor obstructing the left main bronchus. A definitive diagnosis could not be made. After several courses of laser therapy, the airways became completely clear. On pathological examination, the tumor was found to be composed of mucus. Laboratory findings showed an elevated level of IgE concentration and positive precipitating antibodies against A. fumigatus antigen. A chest CT at the time the condition of the patient improved, showed mild central bronchiectasis in the upper lower lobe. We suspected ABPA clinically. Clinicians should be aware that ABPA may cause complete atelectasis of the lung.

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Adenocarcinoma in right S^1a was diagnosed in a 47-year-old man. Before operation, invasion to the corpus vertebrae, trachea and esophagus was suspected and a classification of c-T4N2M0-stage IIIB was made. Preoperative bronchofiberscopy revealed invasion to the membranous portion of the trachea extending for a distance of 7 cartilago rings from the carina. Median sternotomy, in addition to the right cervical incision, thoracotomy at the 4th intercostal space in the right anterior axillary region were performed. Resection of three corpus vertebrae of Th 2-4, the esophageal muscular layer, and the right upper lobe together with resection of tracheal membranous portion was performed. The defect of the tracheal membranous portion was 2.5×1.2cm, and the defect was covered with a pericardiac pedicled patch, additionally the defect in the esophageal muscular layer was reinforced with the 4th intercostal muscle pedicle. Post-operative pathological examination revealed poorly diffentiated adenocarcinoma and p-T4N2M0-stage IIIB. Three corpus vertebrae, esophageal outer membrance muscular layer and the membranous portion of the trachea manifested T4 lung cancer, but resected stump was shown to be all negative. Successive postoperative bronchofiberscopy revealed that the reconstructive portion of pericardiac pedicled patch was completely cured and covered with approximately normal tracheal mucosa on the 50th postoperative day. This technique of the reconstructive operation of the membranous portion of the trachea was reported as one surgical technique which was effective without causing the postoperative complication.

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A 75-year-old man presented at our clinic because of a massive hemoptysis. He had been injured by fragments of a hand grenade 52 years earlier, some of which had followingly been removed from the soft tissie of his back. He had since been asymptomatic. A chest X-ray film disclosed a metallic foreign body in the right upper lung field. Bronchoscopy revealed a foreign body impacted at the orifice of the right B^2 bronchus. Digital subtraction angiography demonstrated a hyper-vascular right bronchial artery, with shunting between bronchial and pulmonary arteries. CT scan also revealed bronchiectatic changes distal to foreign body. We performed a right upper lobectomy. The postoperative course was uneventful. Bronchoscopic removal of foreign body is safe to do with low complication rates, and therefore accepted as the first choice. Surgical interventions are sometimes required, however, especially when the foreign body is located in such a position as is anatomically difficult to access bronchoscopically, or when massive hemorrhage is likely following removal of it. Long-standing intrabronchial foreign bodies, like the one shown above, may better by surgery because of the racemose bronchial arteries as well as the secondary bronchiectasis.

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A 63-year-old woman was admitted our hospital complaining of intractable pneumonia for a long time. Her chief symptom was severe cough attacks. In a local clinic a chest X-ray demonstrated an abnormal shadow on the right lung and she was given anti-tuberculosis agents for six months without improvement. In another hospital, bronchoscopy demonstrated a white foreign body with obstruction of the right basal bronchus. In our hospital, we removed it with a bronchoscope. It was a fruit seed. Cough disappeared and the abnormal shadow on roentgenogram gradually disappeared.

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We report a case of pulmonary actinomycosis induced by tooth aspiration. A 53-year-old man complained of fever, cough, and sputum. He experienced recurrent pneumonia in the right middle lobe. Because of concomitant infectious bullae in bilateral lung apices, he underwent bullectomy and resection of right middle lobe. Pathological examination of the right middle lobe revealed pulmonary actinomycosis. Four months later he was readmitted due to right lower lobe pneumonia. Antibiotics were prescribed and a tooth which was lost a year ago was expectorated. Thus his pulmonary actinomycosis was thought to be induced by tooth aspiration.

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We report a rare case of tracheobronchial injury from aspiration of the alkaline household bleach. An 89-year-old woman ingested household bleach containing 1% sodium hydroxide and 5% sodium hypochloride in a suicide attempt. Three hours later, she was admitted to our hospital complaining of oropharyngeal pain, wheeze and hoarseness. Although laboratory data and chest radiographs were almost normal, endoscopic examination showed a reddish and edematous tracheobronchial mucosa covered with a white coat, in addition to esophageal ulcer and acute gastric mucosal lesion. Bronchial toilet was performed, and the administration of methylprednisolone, sultamicillin tosilate and ranitidine was initiated. The bronchoscopy on the second hospital day revealed much white secretion, and the bronchial biopsy specimen showed round cell infiltrations in the mucosa. On the ninth day, bronchoscopic findings of tracheobronchial mucosa were improved, and the patient was discharged on the seventeenth day without esophageal stricture.

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A 48-year-old man was referred because of an abnormal shadow on a chest X-ray film in November, 1996. Chest tomography, CT scan and bronchoscopic examination showed a tracheal tumor. Chest tomography demonstrated an about 10mm diameter tumor 15mm above the carina. Chest CT showed a sharply demarcated round tumor which arose from the right anterior wall of the trachea, occluding about 30% of the tracheal lumen. Bronchoscopic examination showed a soft polypoid tumor with a yellowish-white, smooth surface and capillary dilatation. The pathological diagnosis was a pleomorphic adenoma. The tumor was removed by circumferential resection of three tracheal rings (about 24mm) and reconstruction of the trachea by end-to-end anastomosis. Histological diagnosis revealed a benign pleomorphic adenoma. The postoperative course was uneventful. The patient's condition is satisfactory 20 months after the operation.

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A 34-year-old man visited our hospital for investigation of abnormal shadows on chest X-ray film. Chest X-ray film and CT scan showed diffuse infiltrative shadows with a peripheral clear zone. Although pulmonary alveolar proteinosis (PAP) was confirmed by bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB), the patient did not agree to transbronchial treatment. During follow-up of the clinical course for one year, the abnormal chest X-ray findings disappeared.

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A 75-year-old man was referred to our hospital because an intratracheal polypoid tumor was detected by fiberoptic bronchoscopy. He had received 71 Gy irradiation for squamous cell carcinoma of the larynx four years before. Histologic examination of the biopsied specimen of the tumor revealed squamous cell carcinoma. Sleeve resection of seven rings of the trachea with primary end-to-end anastomosis was performed through a median sternotomy. Three months after resection of the trachea, chest CT scan showed a mass in left S^6. Percutaneous needle biopsy revealed squamous cell carcinoma and left lower lobectomy was performed. Althogh the laryngeal, tracheal and lung cancers were the same histologic type, the clinical and pathological findings suggested that this case had triple primary cancers.

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An elderly patient with squamous cell carcinoma is reported. Radical treatment was conducted after laser therapy, by which an almost totally obstructed right main bronchus was dilated. An 81-year-old man suffered from bloody sputum and dry cough and consulted another hospital. Fiberoptic bronchoscopic brushing cytology revealed squamous cell carcinoma. Endoscopic findings on admission showed a polypoid lesion which obstructed the right main bronchus incompletely. He complained of severe dyspnea on exertion. Chest CT showed a 2.5×2.0cm mass in the right main bronchus, but the truncus intermedius was patent. The tumor was vaporized with a contact type Nd-YAG laser until a type 1T-10 bronchoscope could pass through the bronchial lumen. Right upper sleeve lobectomy and mediastinal node dissection were conducted. The postoperative stage was T3N0M0 stage IIIA. The postoperative course was complicated with temporary delirium and prolonged air leakage. He was discharged on the nineteenth postoperative day in good condition.

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Expandable metallic stent (EMS) have been frequently employed for the treatment of airway stenosis due to various causes. However, it has been clear that there are some problems associated with EMS. We experienced 3 kinds of problems in 4 out of 6 patients treated by EMS in our hospital. These troubles were (1) intractable cough caused by the irritation caused by the mesh sutured around the EMS to block the intraluminal growth of tumor, (2) fatal intratracheal bleeding due to the injury caused by the EMS, (3) intraluminal growth of lung cancer through the wires of the EMS. All of these problems restricted us from employing EMS without careful consideration. Coughs described in previous reports were not severe, but our case suffered obstinate cough until death in spite of administration of many kinds of antitussive agents. After this experience we did not use a mesh-covered EMS again. Two cases died of intratracheal bleeding. Autopsy performed in one patient revealed the bleeding from the tracheal mucosa injured by the EMS wire. Embolization of the bronchial artery was ineffective in this case. If EMS could have been safely extracted, this complication could be avoided. Tumor growth through the net of the wires of EMS brought about severe stenosis and one patient almost asphyxiated, but the emergency insertion of a Dumon stent into the lumen in the EMS saved the life of the patient. EMS has the excellent feature of early insertion, but our experience taught us the limited clinical indications of EMS. EMS should be employed only in terminal stage patient whose airway is narrowed by extraluminal compression due to tumor.

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