Purpose. Lung cancer and ischemic heart disease, which have been increasing in number, arc closely associated with daily habits. In bronchofiberscopic examination for possible lung cancer patients having such diseases, careful attention during the examination must be paid to avoid hypoxyemia, blood pressure increase, and tachycardia, which may induce deterioration of these underlying diseases. Since 2001, we have started to use general anesthesia in diagostic bronchofiberscopy for such patients as those having ischemic heart disease or severely poor pulmonary function aiming at preventing respiratory and or cardiac complication during the examination. In this report we reviewed 11 cases of bronchofiberscopy under general anesthesia to prove the efficacy of the procedure. Materials and Methods. From June, 2001 through September, 2002, 11 patients received bronchofiberscopy under general anesthesia using propofol and a laryngeal mask among 231 cases of the examination during the period. The effect of general anesthesia was evaluated by blood pressure change, blood gas analysis during the examination, as well as SpO_2 in the recovering stage from anesthesia. Results. Blood pressure during the examination were stabilized in the group with general anesthesia compared with the group with local anesthesia. Recovery from anesthesia was prompt, and no respiratory dysfunction was observed. Conclusion. General anesthesia using propofol and a laryngeal mask at diagnostic bronchofiberscopy was performed in those who had respiratory and cardiac disease. Sedation during the examination was kept with this procedure and recovery from anesthesia was prompt. (JJSB. 2003 ; 25 : 73-79)

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Background. In cases with insertion of the Dumon stent into the upper trachea, maintaining the airway during the procedure and preventing migration of the stent are often major problems. Here we describe how to manage patients with subglottic stenosis before and during stenting and how to fix the Dumon stent to the tracheal wall to avoid migration of the stent. Methods. Under intravenous anesthesia by continuous infusion of propofol, the laryngeal mask-Fastrach^<TM> (LMA-Fastrach^<TM>) was inserted into the pharynx. After the insertion of the fiberscope through the LMA-Fastrach^<TM>, local anesthesia was given using lidocaine for the vocal cord and the tracheal mucosa. The LMA-Fastrach^<TM> was removed, and a rigid bronchoscope was inserted for stent insertion. After completion of the stent insertion, one 18 G and one 16 G intravenous catheter were punctured into the stent percutaneously, under bronchoscopic guidence. Threads were inserted through each catheter into the stent, and then the stent was fixed to the tracheal wall by one or two nylon threads. Conclusions. Even if the endotracheal intubation is difficult due to the stenosis in the subglottic trachea, the airway can be maintained safely and easily using the LMA-Fastrach^<TM>. Moreover, in this procedure, detailed observation of the vocal cord and tracheal wall is possible. The technique for fixation of the Dumon stent described here can be performed in any institution because no special equipment or technique is necessary. (JJSB. 2003 ; 25 : 80-S4)

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Purpose. The causes of diffuse alveolar hemorrhage (DAH) are various and DAH frequently worsens rapidly, so early diagnosis is crucial. In order to clarify the clinical features of DAH, we reviewed the DAH cases we encountered in the past 7 years in our department. Materials and Methods. The clinical features of 10 patients given a diagnosis of DAH between January 1996 and March 2002 in our department were analyzed. Results. Six were men, four were women and the average age was 53.6 years (range 28-75). The causes of DAH were as follows : idiopathic acute eosinophilic pneumonia (one case), drug induced acute eosinophilic pneumonia (one case), fibrosing nonspecific interstitial pneumonia (one case), chronic heart failure due to mitral valve regurgitation (one case), lymphangioleiomyomatosis (one case), inappropriate warfarization (one case), pulmonary amyloidosis (one case), antineutrophil cytoplasmic antibody associated vasculitides (one case), idiopathic alveolar hemosiderosis (two cases). Four cases were treated with pulse therapy with methylprednisolone and one case was treated with pulse therapy with methylprednisolone, cyclophosphamide and plasmapheresis. Three cases improved only by treatment for the original disease. Two cases improved apparently according to the natural course of the disease. Conclusion. The causes of DAH were so variegated, that it is quite difficult to make a definitive diagnosis. Performing BAL was useful for early diagnosis. Although pulse therapy with methylprednisolone and administration of immunosuppressive agents are common, the indications should be determined according to the original disease. (JJSB. 2003 ; 25 : 85-89)

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Purpose. We evaluated the safety and usefulness of the flexi-rigid thoracoscope (Olympus LTF type-240) under local anesthesia for the diagnosis of patients with pleural effusion in an endoscopic room. Patients and Methods. From January to December of 2001 to March of 2002, we performed thoracoscopy in 24 cases with pleural effusion of unknown origin. None of the cases were diagnosed by routine cytologic and bacteriologic examinations of pleural effusion by thoracentesis before thoracoscopy. One flexible trocar entry site, usually located in the midaxillary line in the 6th or 7th intercostal space, can also be used to manipulate the biopsy forceps. We used the LTF-240 thoracoscope (Olympus Optical Co Ltd) with a flexible head stabilized on a rigid body connected with a video system. During thoracoscopy, pleural biopsies may be obtained from areas that appear abnormal, such as granulomas, pleural plaques, small nodules, masses, or other polypoid lesions. Results. Pathological and bacteriological results showed 10 malignancies (35%) and 14 cases of inflammatory pleuritis (65%). Malignant cases included 4 primary lung cancers, 4 metastatic pleural tumors from 2 renal cancers, parotid mucoepidermoid carcinoma, 1 mesothelioma, and 1 primitive neuroectodermal tumor of the chest wall. The pleural surfaces showed multiple nodules in 7 cases, fibrinous pleuritis in 2 cases and pleural thickening in 1 case. The cases of inflammatory pleuritis included 2 cases of tuberculous and 12 cases of nonspecific inflammation. In addition, for therapeutic propose, we eliminated, as much as possible, the multiple partitions caused due to fibrinous adhesions, using forceps and the rigid part of the thoracoscope. This method is very useful for physiological pulmonary expansion. No complication was observed. Except for chest pain and subcutaneous emphysema, there were no serious complications. Conclusion. Thoracoscopy under local anesthesia is indicated for pleural effusion of persistent or unknown origin. This new thoracoscopy is an easy and safe method that can be performed by pulmonary physicians on their own, without assistance by a thoracic surgeon. (JJSB. 2003 ; 25 : 90-96)

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Background/Purpose, Japan has contributed to the development of and advances in bronchoscopes. However, there have been only a few reports on the present status of bronchoscopy, such as the incidence of complications and differences in the frequency of bronchoscopy among institutions. At the 23rd annual meeting of the Kyushu Society for Bronchology of the Japan Society for Bronchology (President, Prof. Kosei Yasumoto) held on August 25, 2000, we asked institutions in the Kyushu district to carry out a questionnaire survey of "The Present Status of Bronchoscopy", and evaluated the responses. Subjects/Methods. Responses were obtained from 41 institutions, with responses from different departments in one hospital being regarded as being from different institutions. Results/Conclusions. Each bronchoscope was used for 35 bronchoscopic examinations (mean). Each physician who can perform bronchoscopy performed it 39 times/year (mean), and each board certified member of the Japan Society for Bronchology (BCMJSB) and each authorized instructor of the Japan Society for Bronchology (AIJSB) examined 288 and 257 cases (mean), respectively. At institutions where both BCMJSB and AIJSB work, the incidence of complications was high, and informed consent was often obtained in writing. The risk of contamination by acid-fast bacteria due to bronchoscopy was reported by about 50% of the institutions. At institutions reporting contamination, anti-contamination measures other than those in the manual were taken. In bronchoscopy, adequate consideration appeared to be given to the education of physicians who perform bronchoscopy, obtaining informed consent from patients, and measures against secondary infection. (JJSB, 2003 ; 25 : 97-104)

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Purpose. We report two cases of intrabronchial early cancer which completely disappeared following weekly chemotherapy using paclitaxel and carboplatin. Cases. Case 1 was a 69-year-old man who suffered lung metastasis from rectal cancer. On bronchoscopic examination, tumor at the orifice of B^1 + B^2 was detected incidentally. Biopsy yielded a diagnosis of squamous cell carcinoma. The tumor was not detected by chest CT and it was considered to be early stage cancer. After six weeks administration of paclitaxel and carboplatin, the tumor disappeared even on microscopic examination. After 1.8 years from starting chemotherapy, no recurrence of the lung cancer was detected. Case 2 was a 66-year-old man who suffered from bloody sputum. At, bronchoscopy, a large tumor at the bifurcation of the left upper and lower lobe, and a small tumor at the bifurcation of the right B^8 and B^9 were detected. The two tumors were diagnosed as squamous cell carcinoma by punch biopsy. The right side tumor was considered to be early cancer. After six weeks of administration of paclitaxel and carboplatin, the right side tumor disappeared on microscopic findings. Results. Chemotherapy using paclitaxel and carboplatin is thought useful for treatment of early lung cancer. (JJSB. 2003 ; 25 : 105-109)

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Case. This is a case of a 67-year-old man who underwent low-anterior resection for rectal carcinoma 11 years previously and a right lower lobectomy for pulmonary metastasis 5 years previously. He consulted our clinic because of cough. Bronchoscopy revealed a pedunculated tumor in the left main bronchus. It was initially considered an endobronchial metastasis from rectal carcinoma by exfoliative cytodiagnosis. The tumor was removed by an electrosurgical snare, and the stump was cauterized by a diode laser. Postoperative pathological diagnosis revealed moderately differentiated adenocarcinoma metastatic from the rectum. Bronchoscopy 2 months after the procedure revealed recurrence at the site of resection. This was treated by external (total 40 Gy) and intracavitary (total 16.5 Gy) irradiation with ^<192>Ir to the tumor. Follow-up study exfoliative cytodiagnosis was negative. Subsequent evaluation after 18 months revealed no recurrence. Conclusion. Bronchoscopic treatment with combined radiotherapy was effective for this case of local intracavitary endobronchial metastasis. (JJSB. 2003 ; 25 : 110-113)

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Background, Argon plasma coagulation (APC) has been mainly used to treat gastrointestinal hemorrhage, but has recently also been applied to the treatment of airway stenosis. Case. A 48-year-old woman who had undergone right nephrectomy because of renal cell carcinoma at age 40 complained of dyspnea and cough in April 2000. Bronchoscopic examination revealed severe stenosis of the left main bronchus due to endobronchial metastasis of renal cell carcinoma and stenosis of the right truncus intermedius due to extrinsic compression caused by right hilar lymph nodal metastasis. The tumor in the left main bronchus was removed by forceps under bronchoscopy with the use of APC. Then, a Z stent could be successfully inserted into the right truncus intermedius, which led to the dramatic improvement of her symptoms. Conclusion. The use of APC was effective for the treatment of airway stenosis in this case. (JJSB. 2003 ; 25 : 114-117)

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Background. Although an ultra-thin fiberoptic bronchoscope (Olympus BF-2.2T, outer diameter 2.2mm) allows direct observation of peripheral airways, it is limited in the images it can obtain, due to the fiberoptic scope itself. Purpose. To improve the quality of the images, we developed a new ultra-thin bronchovideoscope (XPF-240Y1), which has the same outer diameter as the BF-2.2T in cooperation with Olympus Co., Ltd. The XPF-240Y1 is a videoscope, which not only has the smallest CCD in the world, but powers a magnifying power of a maximum of 70 times. Methods. We performed peroral ultra-thin bronchoscopy in five patients with or without COPD. The XPF-240Y1 was inserted and wedged in as many peripheral airways as possible, the airways were observed and photographed with an SC 16 camera. We compared the feasibility of these two scopes, in particular the obtained photographic images. Results. Using the XPF-240Y1, we could directly observe down to the 12th generation bronchial branches in all patients. No significant differences were found in manipulation between the two scopes, but the photographic images obtained with the XPF-240Y1 were clearer than those obtained with the BF-2.2T, in particular showing such findings as engorgement of blood vessels and mucosal irregularity. Conclusions. The XPF-240Y1 allowed not only direct, but detailed observation of mucosal changes in small airways, because of its videoscopic magnifying power. This new ultra-thin videoscope is useful for evaluation and morphological diagnosis of small airways in vivo. (JJSB. 2003 ; 2 : 118-122)

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