Background and Aim. The majority of patients who undergo bronchoscopy feel anxiety and discomfort. Therefore, most of them prefer to be sedated during this procedure. However, sedation has the risk of complications caused by respiratory depression. The aim of this study was to evaluate the usefulness of transcutaneous CO_2 pressure (PtcCO_2) measurement as a tool for monitoring respiratory condition during flexible bronchoscopy under sedation. Methods. We studied 88 consecutive patients who underwent bronchoscopy. They consisted of 52 men and 36 women of mean age 67.1 years. Bronchoscopy was performed under sedation with intravenous midazolam. Arterial blood gas analysis was done before and during the sedation. During the procedure, patients were given supplemental oxygen and we monitored blood pressure, electrocardiogram, pulse oximetric saturation (SpO_2) and PtcCO_2. Results. The mean baseline PaCO_2 value was 42.8mmHg. Mean change in PaCO_2 measurement from the baseline was 4.9mmHg. Mean increase of PaCO_2 was larger in women than in men. Age, body weight, midazolam dosage per body weight and the pulmonary functional factors which we examined, were all unrelated to the degree of PaCO_2 change. In this examination, PtcCO_2 values demonstrated a high degree of correlation with PaCO_2. Serious complications did not happen in any case in this study, but there were a few cases that showed unexpectedly high PaCO_2 elevation. In this investigation, patients with more than a 15 mmHg elevation of PaCO_2 from the baseline value or critical decrease of SpO_2, had bronchial asthma or obstructive sleep apnea syndrome. Conclusion. Flexible bronchoscopy performed under sedation may cause respiratory depression. PtcCO_2 measurement is useful to non-invasively and continuously evaluate hypoventilation during this procedure.

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Background. Nocardial infections are being diagnosed with increasing frequency, but cases of intractable pneumothorax associated with pulmonary nocardiosis are very rare. We report a case of effective endobronchial treatment using an Endobronchial Watanabe Spigot (EWS) for pneumothorax associated with pulmonary nocardiosis. Case. A 60-year-old man under treatment with prednisolone for nephrotic syndrome underwent insertion of a chest drainage tube and was placed on artificial ventilation because of respiratory failure due to pulmonary nocardiosis and secondary pneumothorax. While a subsequent change of the antibacterial agent control of the lung lesion and inflammatory marker, air leak continued for 34 days. We tried bronchial embolization using EWS in the involved bronchus and were able to obtain good lung expansion. The patient was then weaned from artificial ventilation and extubated. No complications occurred. Conclusion. We report a rare case of effective endobronchial treatment using EWS for intractable pneumothorax associated with pulmonary nocardiosis.

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Background. Cases currently classified as leiomyosarcoma of the bronchus sometimes show good prognosis. Case. A 19-year-old woman with bronchial asthma visited our hospital. Chest X-ray showed a 15-mm-diameter nodular lesion in the left middle lung field. The nodule was in diagnosed to be a mucous plug, and intensive treatment of bronchial asthma was initiated. Though the symptoms were successfully controlled, the nodule grew, with a tumor doubling time of 140 days, so we performed transbronchial tumor biopsy. Histological findings suggested a smooth muscle tumor. The possibility of pulmonary metastasis from a hysteromyoma or a soft tissue tumor was denied clinically. After surgical resection, the tumor was diagnosed as leiomyosarcoma of the bronchus and free of relapse over 4 years. Conclusion. Although this case was classified as leiomyosarcoma under the current classification, it was histologically similar to a smooth muscle tumor of uncertain malignant potential, and postoperative outcome was excellent. This case suggests further need for discussion on histological reclassification of smooth muscle tumors of the lung, following the example of soft tissue tumors.

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Background. Bronchial involvement of Wegener's granulomatosis (WG) is very rare. We report a case of WG presenting with various types of bronchial involvement, referring to previous reports and adding to our consideration. Case. A 55-year-old woman was referred to our hospital because of otorrhea and hearing loss. At first a diagnosis of exudative tympanitis was made, and right side tympanoplasty was performed. After 2 months, she was admitted to our hospital for left side tympanoplasty. At hospitalization, a chest X-ray abnormality was poined out. Chest CT scan showed a mass with cavitation in the right lower lung field and stenosis of the left main bronchus. Moreover, WG was suspected because of PR3-ANCA elevation. She only had mild cough. However, on flexible bronchoscopy, the trachea and bilateral main bronchus showed various findings of protrusions, stenosis, ulcerative bronchitis and so on. Transbronchial biopsy was done, and the histologic findings of the right B^9_b showed infiltration of lymphocytes and surrounding multicentric giant cells with granulomatous features. WG was diagnosed. Treatment with high dose prednisolone and cyclophosphamide markedly improved her symptoms and bronchoscopic findings. Conclusion. This case report emphasizes various types of tracheobronchial involvement in WG despite only mild respiratory symptoms.

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Case. A 78-year-old man with dyspnea was admitted to our hospital. His chest X-ray showed nodules in both upper lung fields. A polypoid tumor at the orifice of right B^8_a was detected by bronchofiberscopy. The tumor was removed by biopsy. The histological examination revealed that the nodule consisted of mature fat cells proliferating under the bronchial membrane. We diagnosed endobronchial lipoma. Meanwhile, the nodule detected in right S^3_a was squamous cell carcinoma of the lung. Conclusion. Endobronchial lipoma is very rare tumor and only 6 cases accompanying lung cancer have been reported in Japan. Therefore, the present case is considered noteworthy.

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Background. Although surgical resection is a standard treatment for bronchial carcinoid, bronchoscopic approaches such as laser coagulation, photodynamic therapy, and electrocautery for intraluminal typical bronchial carcinoid (ITBC) are also useful. We here report a case with ITBC that was well controlled by interferon-alpha (IFN-alpha) as adjuvant therapy for hepatocellular carcinoma (HCC) followed by bronchoscopic hot biopsy. Case. A 59-year-old man, for whom IFN-alpha was administered as adjuvant therapy after resection of HCC, complained of bloody sputum. Computed tomography (CT) scan of the chest revealed atelectasis of the right middle lobe. A submucosal tumor occluding the middle lobe bronchus was observed bronchofiberscopically and was histologically diagnosed as ITBC by transbronchial biopsy. Conventional surgical resection was considered for treatment, but close follow-up by bronchoscopy was selected because of the poor prognosis of HCC and the slow growing nature of ITBC. Thereafter, the ITBC became smaller. The remaining tumor was completely resected by subsequent bronchoscopic hot biopsy. One year and 6 months after completing IFN-alpha therapy, the patient remains well without evidence of local recurrence or distant metastasis. Conclusion. IFN-alpha administration and bronchoscopic hot biopsy were effective for the treatment of ITBC.

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Background. Spontaneous hemopneumothorax is a rare clinical entity, defined as the accumulation of blood in the pleural cavity in association with spontaneous pneumothorax. Since over 30% of spontaneous hemopneumothorax develops hemorrhage shock, early diagnosis and treatment is required. Case. We report 2 cases of spontaneous hemopneumothorax. A 20-year-old man (Case 1) and a 29-year-old man (Case 2) presented at our hospital with right-sided chest pain and dyspnea. After tubal thoracostomy, collapsed lung was not reinflated in Case 1 and bloody fluid was drained continuously in Case 2. So the patients eventually underwent emergency VATS. Results. In both cases, damaged aberrant vessels between the bullae and apical portion of the parietal pleura was noted. Bullectomy and clipping of the aberrant vessels were performed. The postoperative course was uneventful. Conclusion. Spontaneous hemopneumothorax consists of 3% of pneumothorax. It has the risk of hemorrhage shock due to massive bleeding. Therefore, prompt diagnosis and treatment are essential for this life-threatening condition.

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