[in Japanese]

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Purpose. Bronchoalveolar lavage (BAL) is widely utilized in the diagnosis, pathogenesis and prognosis of interstitial pneumonia (IP). In this paper, the role of BAL is clarified in the representative IP cases, such as sarcoidosis, idiopathic interstitial pneumonias (IIPs) and hypersensitivity pneumonitis (HP). Methods. Published papers about these diseases were reviewed. Results. Even if a definitive diagnosis of these diseases was not made from BAL findings, sarcoidosis and HP showed lymphocytosis and the CD4/CD8 ratio tended to be greater than 3.5 in sarcoidosis and lower than 1.0 in HP. As for IIPs, lymphocytosis had been considered to be useful in the differential diagnosis of idiopathic pulmonary fibrosis (IPF) from cryptogenic organizing pneumonia or nonspecific interstitial pneumonia (NSIP). Recently BAL is not considered to discriminate between IPF and fibrosing NSIP. In the pathogenesis of IP, concentration of cytokines and chemokines correlated with cellularity. Predominace of Th2 cytokines and increased matrix metalloprotease were involved in the fibrosis. Conclusion. BAL is useful in the study of pathogenesis rather than diagnosis or evaluation of the prognosis.

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Although identification of the causative microorganism is essential for the diagnosis of lung infection, it,s detection rate is relatively low from sputum specimens. Furthermore, sputum may not provide sufficent diagnostic yield for the diagnosis of opportunistic lung infection in immunocompromised hosts. Invasive sampling methods such as bronchoalveolar lavage (BAL), fibrobronchial aspiration and endotracheal aspiration enabled us to sample specimens directly from the infected lower respiratory tracts. These sampling methods improve identiflication rates of microorganisms which cause bacterial pneumonia , Legionella penumonia, Pneumocystis carinii pneumonia, Cytomegalovirus pneumonia, pulmonary mycobacterial infection and fungal pneumonia. The biochemical characteristics of BAL fluid may help consolidate the diagnosis of lung infection. It is expected that liquid biopsy performed in the lower respiratory tract improves diagnostic yields in lung infection.

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Bronchoalveolar lavage (BAL) is a well-established technique to harvest inflammatory cells and epithelial lining fluid from peripheral airways and alveoli. This method yields the information on localized inflammation, such as soluble mediators and cytokines. BAL is sometimes contraindicated for chronic obstructive pulmonary disease (COPD) patients because of the collapse and/or occlusion of airways, resulting in poor recovery of the instilled fluid. We have applied BAL to investigate the pathophysiology of pulmonary emphysema at early stage. The findings suggest that neutrophil-related inflammation is present only in the peripheral airways/alveoli of smokers with emphysematous changes detected by high resolution CT scans, but not in healthy smokers. Recently, Ishizaka et al. have developed a novel technique, bronchoscopic microsampling (BMS) to obtain airway epithelial lining fluid. We found BMS to be safe and feasible for advanced COPD patients. We focused on the neutrophil-related inflammation and assessed the sitedependent differences between upper and lower airways. In conclusion, the application of BAL and/or BMS methods may not necessarily essential for the clinical diagnosis of COPD today, but they could give new insights into the pathogenesis of COPD, leading to the development of new treatments for COPD.

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According to progression of bronchoscopic diagnosis and molecular biology, lung tumors are diagnosed using analysis of bronchial and bronchoalveolar lavage and lining fluid collected by microsampling probe. This paper reviews analyses of soluble molecules in lavage and lining fluid and exfloliated cells in lung cancers and malignant lymphomas.

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Purpose. We evaluated the efficacy and problems of tracheobronchial stents for airway disease. Materials. We evaluated 23 patients (34 cases) who received stent implantation after 1992. The primary diseases were lung cancer (13), esophageal cancer (3), renal cell cancer (1), thyroid cancer (1), trauma (2), relapsing polychondritis (2), tuberculosis (1) . Results. The stenotic site was the trachea in 8 cases, right main bronchus in 8 cases, truncus intermedius in 3 cases, left main bronchus in 14 cases and left basal bronchus in 1 case. Insertion was performed under general anesthesia in 27 cases, under local anesthesia in 7 cases and under PCPS in 3 cases. Improvement of dyspnea was obtained in 96%, and improvement of symptoms due to tracheobroncho-esophageal fistulas and anastomotic leakage was obtained in 60%. Complications were observed in 9 cases (39.1%) . They consisted of 1 case of bleeding (Dumon stent), 2 granulations (1 with a Z stent, 1 with a Dynamic stent), 1 break (Dynamic stent), 5 migrations (1 with a Z stent, 4 with a Dumon stent), 1 atelectasis due to size mismatch (Dumon stent) and 2 infections (both Dynamic stents). We evaluated the duration and complications in benign airway stenosis and anastomotic leakage, because of longerterm placement than in malignant stenosis. Z stents and Ultraflex stents were implanted in 7 patients for between 1 to 131 months with no complications and showed stable effects. All 3 Dumon stents were removed immediately due to migration. Dynamic stents were implanted in 2 patients for 75 and 29 months and infections complicated both. Conclusion. Stent treatment for airway stenosis is useful, if the proper type and size of stent is selected, but stent treatment for airway fistula is difficult. For benign airway disorders, we must carefully choose the most suitable stent for each case needing long-term stent placement.

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Background. Transbronchoscopic microwave tumor coagulation has some advantages compared to laser treatment. 1: Ability to coagulate an extensive longitudinal airway area. 2: Less bleeding no production of smoke. 3: Cost-effective. Its major disadvantage is the longer time required to achieve the effect. In 1999 the TE-24BL longroller type microwave electrode become available for transbronchoscopic treatment. TE-24BL has a central electrode converting of a 2.4 mm (diameter) × 4 mm (length) cylinder. Purpose. In this report, we evaluate the efficacy of TE-24BL comparing to TE-24B (ball type). Results. The median area, coagulated at 50 W for 10 seconds by the TE-24B and TE-24BL were 56 mm^2 and 144 mm^2 respectively, and the median periods for coagulation of tracheal inflammatory polyps were 36.2 and 24.3 minute respectively. Conclusion. A longroller type electrode can achieve prompt effects, because it can coagulate a larger area than a ball type electrode.

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Backgrouud. We retrospectively evaluated the efficacy of stenting for inoperable stenosis of the central airways and/or tracheobroncho-esophageal fistulas and studied more safe and reliable techniques. Method. Treatment for airway stenosis was performed with a combination of surgical techniques using various devices [highfrequency electrocautery snare, Nd-YAG laser, argon plasma coagulation (APC)] and a debulking technique with the rigid bronchoscope. Furthermore, hyper frequency jet ventilation (HFJV) via a Mini-Trach II which was inserted to the cricothyroid ligament prevented poor oxygenation and raised the operative performance during the use of the rigid bronchoscope. In 36 patients (mean age, 66.4 years, 25 men and 11 women), after dilatation of the airways, 44 stents were inserted according to the condition of the patient. Double-stents were inserted to both the airway and the esophagus in 9 patients with tracheobroncho-esophageal fistula and one with esophageal stenosis. Results . The inserted stents were 9 Z-stents in 7 patients, 10 Ultraflex stents (including 6 covered type stents) in 9 patients, 21 Dumon stents (including 5 Y-shaped types) in 19 patients and 4 TM-stents (including 2 Y-shaped types) in 3 patients. Nineteen complications occurred in 34 procedures. One severe hemorrhage at coring out and one airway burning by Nd-YAG laser occurred during the use of the rigid bronchoscope. The other complications related to insertion of stents were: tumor ingrowih (n=2) and fracture (n=1) in Z-stent; refractory cough (n=4) , tumor overgrowth at the distal end of the stent (n=2), granulation tissue overgrowth at the distal end of the stent (n=2) and retained tenacious sputa (n=2) in Dumon stents; reopened fistula (n=2) and esophageal bleeding (n=2) in esophageal stents. Improvement of dyspnea (Hugh-Jones grade) and performance status were seen in 530/0 (19/36) and in 670/0 (24/36), respectively. Ten patients with esophageal fistula could swallow some food after the procedure, with massive expectoration of watery discharge, except for two patients with recurrent nerve palsy. In malignant cases survival analysis was performed to compare the two groups subdivided according to adjuvant therapy: 17 underwent adjuvant irradiation with or without chemotherapy (group A), and 15 did not (group B). In group A, two fatal cases of hemoptysis and two severe pneumonias occurred. Median survival time was 5.6 months in group A and 1.3 months in group B: there was significant difference between the two groups. Couclusious. The patients with central airways stenoses and/or tracheobroncho-esophageal fistulas obtained immediate relief of airway complaints by multimodal treatment. In dilatation of stenoses by the rigid bronchoscope, HFJV via a Mini-Trach II is useful to avoid poor oxygenation during these procedures. We considered that silicone stents should be selected first, and that covered metallic stents should be used in cases of severe deformation of the airway. Adjuvant irradiation and/or chemotherapy should be performed in cases which were improved by airway stenting, however careful management is necessary for early detection of severe complications related to adjuvant therapy.

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Background. Stent placement has become the standard treatment for airway stenosis. Purpose. We examined the effectiveness and problems of stent treatment by presenting a series of patients who submitted stents for airway stenosis in our center. Methods. Between January 2001 and May 2003, 18 patients submitted stents for airway stenosis, 13 with malignant disease and 5 with benign disease. Results. The13 patients with malignant disease consisted of 7 with lung cancer, 5 with esophageal cancer, and 1 with lung metastasis from thyroid cancer. The site of stenosis was the trachea in 2 patients, around the carina in 7 patients, the right main bronchus in 1 patient, and the left main bronchus in 3 patients. We placed a Dumon stent (straight) in 7 patients 8 times, a Dumon stent (Y-shaped) in 8 patients 8 times, and an Ultraflex nitinol stent (covered) in 4 patients 8 times. The complications of stenting were accumulation of airway secretions in 4 patients, stent displacement in 2 patients, aspiration due to tracheo-esophageal fistula in 2 patients, and restenosis due to tumor regrowth in 1 patient. The mean survival time after stent placement was 166.5 days. The site of stenosis in 5 patients with benign disease (children with severe psychosomatic disorders) was the trachea in 3 patients, from the trachea to the carina in 1 patient, and the left main bronchus in 1 patient. Of these patients, 4 received a Dumon stent (straight) 6 times, 1 with a Dumon stent (Y-shaped) once, and 2 with an Ultraflex nitinol stent(covered) 3 times. The complications were granulation tissue formation in 5 patients, stent displacement in 2 patients, stent rupture in 1 patient, and tracheo-innominate artery fistula in 1 patient. Conclusions. Long-term survival was observed in lung cancer in which post-stenting chemotherapy was effective and in esophageal cancer for which a combinated stent was placed more than once. Since stent placement for benign disease is associated with intractable or fatal complications, the indications should be carefully determined.

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Background. Endoscopic electrosurgery using a high frequency to generate heat is a very useful method for central airway obstruction in termes of effects, cost, and technique rather than other methods. In patients, endobronchial polypectomy for large polypoid lesions is a very effective and safe method using electrosurgery with a snare wire. Purpose. Safe and effective methods of polypectomy using a high frequency snare wire for tracheobronchial tumors were investigated. Methods. In our hospital, we performed this method under both general anesthesia and local anesthesia by fiberoptic bronchoscopy for two malignant and three benign tracheobronchial tumors. Results. There were minimum complications such as bleeding and/or dyspnea. Conclusion. Endobronchial polypectomy is a safe and effective method for tracheobronchial tumors. In future, we hope that this safe and effective method will be adopted by many other hospitals.

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Background. Little is known about primary type Mycobacterium avium-intracellulare complex (NLAC). Purpose. To evaluate the clinicopathological findings of MAC infection without underlying lung disease, a prospective bronchoscopic study was planned. Subjects aud Methods. The subjects consisted of 31 cases (27 women, 4 men), whose bronchial lavage fluid revealed positive results with MAC. Transbronchial lung biopsy was performed to evaluate endobronchial observation and histological findings. Results. Bronchoscopic findings showed purulent sputum in some cases, but no specific findings. The most significant histological appearance was broncho-bronchiolitis with more infiltration by lymphocytes than granulomatous inflammation with caseous necrosis. Couclusion. It has already been reported that computed tomography and pulmonary function tests showed small airway abnormality in MAC. This study proved that the histological presentation of MAC infection is lymphocytic bronchiolitis in small airways.

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Background. Pulmonary cryptococcosis shows various radiographic changes but only a single lobe was involved in the majority of the cases. We report a case of pulmonary cryptococcosis indicated by brushing cytology specimens with multiple cavities. Case. A 16-year-old boy was referred to our hospital because of bloody sputum, fever and multiple cavities on a chest X-ray film. A diagnosis of pulmonary cryptococcosis was made by brushing cytology specimens showing round fungi, in addition to positive cryptococcal antigen in the serum. The patient was treated with fluconazole for 6 months. Conclusion. There are few case reports of pulmonary cryptococcosis with multiple cavities. It is necessary to carefully observe patients with cavities on chest X-ray film.

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Background. Rigid bronchoscopes have been used to extirpate foreign bodies in the airways of children. We report the use of this maneuver in the removal of airway foreign bodies in two young children. Case 1. A 2-year-old male infant was admitted on the 8th day after mis-swallowing a peanut. A size 2 laryngeal mask was positioned and then we inserted a fiberoptic bronchoscope (5.2 mm diameter) into the trachea. A biopsy forceps was used through the channel of the fiberoptic bronchoscope to remove the foreign body in the right main bronchus bit by bit. Case 2. A 32-month-old male infant was admitted on the 5th day after mis-swallowing an almond. We employed a size 2 laryngeal mask and a fiberoptic bronchoscope. The foreign body in the right main bronchus was extirpated using a biliary basket in total. Conclusion. The conbined use of a fiberoptic bronchoscope and a laryngeal mask to extirpate airway foreign bodies in 2-year-old children was effective. In particular, the biliary basket was easy to manipulate and facilitated extirpation of the foreign body in total. Providing oxygen through the forceps channel was beneficial to maintain a clear view and oxygenation.

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Background. We report a case of rheumatoid arthritis (RA) with methotrexate (MTX)-induced interstitial pneumonia diagnosed by a positive drug lymphocyte stimulation test (DLST) using bronchoalveolar lavage fluid (BALF) lymphocytes and the clinical course. Case. A 41-year-old female developed non-productive cough and exertional dyspnea a month after initiation of MTX treatment for RA. And after five months, a chest X-ray film revealed interstitial shadows. After discontinuance of MTX, and administration of corticosteroids, her complaints reduced and interstitial shadows improved. Although DLST for MTX using peripheral blood was negative, DLST using BALF lymphocytes was positive. Conclusion. It is suggested that DLST using BALF lymphocyles, but not peripheral blood lymphocyles, is useful for the diagnosis of MTX-induced interstitial pneumonia.

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