Objectives. At our hospital, the number of the incidents of bronchoscope damage and the associated repair costs tended to increase with the number of bronchoscopy procedures performed. We implemented an educational training program for the purpose of promoting proper use and safety management of bronchoscopes, and examined the program's effectiveness. Methods. The study targeted a period from 2005-2007, during which no educational training was provided, and a period from 2008-2010, during which educational training was provided. We compared the two periods in terms of the number of bronchoscopy procedures performed, the number of damage incidents, the repair costs, and the details of damage. Materials. The educational training program consisted of the following: 1) lectures and hands-on training regarding important points to note when handling a bronchoscope; 2) investigations, involving user interviews, upon the occurrence of damage to a bronchoscope, and delivery of the investigation results to doctors who perform endoscopy, in order to promote their awareness; and 3) posting of information on our hospital intranet homepage regarding endoscope construction, how to clean/disinfect/handle endoscopes, etc. This educational training was also performed for all nurses and technicians who are involved in bronchoscopy. In addition, it was made mandatory for all doctors using a bronchoscope for the first time to master bronchoscope operation using a simulator. Results. In the period when training was not implemented, the number of bronchoscopy procedures performed per year was 449.3 (373-522), the number of damage incidents per year was 10.7 (9-14), and annual repair costs were \3,503,616 (\2,995,000-\4,031,000). When the program was implemented, these data were 481.3 (386-572), 3.3 (1-5) and \609,055 (\138,000-\938,000), respectively. Thus, the number of damage incidents and repair costs were significantly reduced by our efforts. Conclusion. By implementing educational training that targeted all doctors who use bronchoscopes, consistency can be achieved in the use of these instruments. Doctors' awareness regarding the proper handling of bronchoscopes was enhanced, contributing to a reduction in the number of damage incidents and associated repair costs. Furthermore, by taking rapid action when damage occurred, it was possible to prevent further damage and also to reduce repair costs.

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Background. Endobronchial ultrasound-guided transbronchial biopsy using a guide sheath (EBUS-GS) has become a common technique in transbronchial biopsy. However, the value of choosing this procedure over standard bronchoscopy in a clinical setting remains unclear. Here, we retrospectively analyzed the utility of EBUS-GS for different kinds of lesions. Materials and Methods. Factors influencing diagnosis in patients who underwent transbronchial biopsy in our hospital from April 1, 2010 to March 31, 2011 were identified and statistically analyzed. Results. The diagnostic yield of lung cancer in patients who underwent EBUS-GS was 69.4%. Nodules in which a solid component was revealed on both chest computed tomography (CT) and X-ray were easily diagnosed by EBUSGS, and those with a diameter of over 20mm increased the diagnostic yield. This represented a statistically significant difference (p<0.05) between patients who underwent EBUS-GS and those who underwent standard bronchoscopy. In the patients who underwent standard bronchoscopy, nodules with a diameter of over 40mm led to a statistically significant increase in the diagnostic yield (p<0.001). No statistical differences were observed between the EBUS-GS and standard bronchoscopy group in anesthesia-related or other complications. However, a statistically significant difference was seen between groups in relation to radiation dose (p<0.001). Conclusions. EBUS-GS appears adequate for the diagnosis of small nodules; however, it does not appear suitable for the diagnosis of nodules that are either undetectable on X-ray or mainly visible as ground-glass opacities on chest CT. Furthermore, higher doses of radiation were necessary for patients in the EBUS-GS group than for those in the standard bronchoscopy group.

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Background. The main cause of broncholith formation is thought to be the penetration of calcified lymph node into the bronchus. However, it is very rare to actually observe the penetration of broncholith into the bronchus using bronchoscopy. Case. An abnormal shadow was identified on the chest X-ray of an 80-year-old female referred to our hospital for a further examination. Chest CT showed a calcified nodule in the proximal portion of the right middle lobe with middle lobe atelectasis. Bronchoscopic examination revealed obstruction at the orifice of the right middle lobe bronchus with mucosal edema, while the pathological findings showed inflammatory cell infiltrates with a normal bronchial epithelium. We performed bronchoscopy again because of the enlargement of the abnormal shadow. The results demonstrated an irregularly-shaped broncholith in the orifice of the right middle lobe bronchus, that exhibited a cozy relationship with its surroundings. We removed the lesion using bronchoscopy. The pathological findings of the broncholith and the patient's clinical course suggested that the broncholith was caused by a calcified lymph node that had penetrated into the bronchus. Conclusion. We herein reported an actual case of a broncholith penetrating into the bronchus observed on bronchoscopy. This case supports the theory that broncholiths are caused by the penetration of calcified lymph nodes into the bronchus.

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Background. Racemose hemangiomas of the bronchial arteries often occur on the right side. We present a case on the left side presenting with hemoptysis. Case Report. A 75-year-old man on warfarin therapy due to a previous stroke presented with hemoptysis. Bronchoscopy showed active bleeding from B^9 and B^<10> on the left, which was controlled with a transbronchial thrombin injection, discontinuation of warfarin, and an intravenous vitamin K injection. Computed tomography showed dilated and meandering bronchial arteries in the left lower lobe of the lung. We diagnosed bleeding from the left B^9 and B^<10> bronchial segments due to racemose hemangioma. Left basal segmentectomy was performed to prevent future bleeding episodes. Since the surgery, the patient has been doing well without hemoptysis. Discussion. Although transcatheter bronchial artery embolization and ligation of the bronchial artery via thoracotomy are sometimes performed as less invasive procedures to prevent bleeding from racemose hemangiomas, lung resection is the most effective therapy when the origin of the bleeding is confirmed.

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Background. Several bronchoscopic treatments for tracheal granular stenosis have been reported, but since they are invasive and they require care concerning complications and cost. Inhaled corticosteroid, the key drug to inflammatory airway disease especially bronchial asthma, is comparatively safe and inexpensive. We report a case of granulomatous tracheal stenosis after tracheoplasty treated successfully only with fluticasone inhalation. Case. A 67-year-old woman had undergone tracheoplasty due to post-intubation tracheal stenosis. Three months after the operation, she was admitted due to recurrence of dyspnea. After bronchoscopic confirmation of the re-obstruction with a granulomatous anastomosis lesion, we treated with inhaled fluticasone and her symptoms improved in a few days. Four months later, we bronchoscopically confirmed the disappearance of the granulomatous lesion. Conclusion. Inhaled corticosteroid is one of the effective treatments for granulomatous tracheal stenosis.

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Background. Elevation of adenosine deaminase in pleural effusion is known to be a characteristic feature of tuberculous pleuritis. Case. A 65-year-old man suffered from right pleuritis and the effusion was exudative with increased adenosine deaminase (132U/l). Then he complained of swelling, pain and rigidity of his hand and finger joints. We suspected he suffered from rheumatoid arthritis. Left pleural effusion appeared and was also exudative with increased adenosine deaminase (81.6U/l) and lymphocytic predominance. We performed thoracoscopy in the right thoracic cavity under local anesthesia but there was no caseating granuloma in his pleural biopsy specimen. We diagnosed rheumatoid pleuritis because rheumatoid factors in bilateral pleural effusion were elevated, QuantiFERON TB 3G(R) was negative and the diagnostic criteria for rheumatoid arthritis were met. His bilateral pleural effusion disappeared after we initiated 5mg prednisolone followed by 6mg methotrexate. Conclusion. Rheumatoid pleuritis is considered in the differential diagnosis of elevation of adenosine deaminase in pleural effusion. Elevation of rheumatoid factor in pleural effusion and confirmation of the pathological examination concerning the existence of caseating granuloma is useful in the diagnosis of rheumatoid pleuritis.

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Background. Solitary fibrous tumor (SFT) is a rare tumor of mesenchymal origin that occurs preferentially in the pleura. When a solitary thoracic nodule is detected in a patient suffering from any type of cancer, it is difficult to determine whether the nodule is a metastatic lesion or a de novo primary thoracic tumor. Case. A 62-year-old man, previously treated for stage IB renal cell carcinoma by nephrectomy, was admitted to our hospital for further examination following detection of a solitary thoracic nodule, which was suspected to be thoracic metastasis. The patient underwent computed tomography (CT)-guided lung biopsy and SFT was subsequently diagnosed, although hemothorax occurred due to intercostal artery laceration. Video-assisted thoracoscopic surgery (VATS) was performed and no recurrence has occurred thus far. Conclusion. When a solitary thoracic nodule is detected in a patient suffering from any type of cancer, SFT should be considered in the differential diagnosis, and surgical resection may be considered as initial treatment if the primary tumor is controlled, no extrathoracic metastases are present, and the patient is in good enough condition to undergo the operation.

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Background. A case of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma shows diverse patterns of radiological and pathological findings with inflammatory changes. Case. A 54-year-old woman was referred to our hospital for examination of a solitary mass in the right lower lung field. The mass showed increased fluorine-18-fluorodeoxyglucose accumulation on positron emission tomography. Transbronchial biopsy (TBB) of the mass was performed, when the endobronchial ultrasonography probe was located adjacent to the lesion. Pathological examination of the TBB specimen indicated foamy macrophage infiltration into the alveolar space, findings suggestive of organizing pneumonia. Because of the inconsistency between the radiological and pathological findings, malignancy could not be ruled out, and therefore, video-assisted thoracoscopic surgery (VATS) was performed. On examination of the VATS specimen, the resected mass showed neoplastic lymphocytic infiltration, forming a tumor with marked granulomatous reaction. The final diagnosis was pulmonary MALT lymphoma with granulomatous reaction based on immunohistochemical staining and in-situ hybridization results. Additional treatment was not administered because the patient was classified as having stage IE disease. Conclusion. Diagnosis of pulmonary MALT lymphoma with granulomatous reaction based on TBB specimens should be made with caution. VATS should be considered when pathological findings are inconsistent with the clinical course or imaging findings in a patient suspected of having pulmonary MALT lymphoma.

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Background. Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is a useful and safe procedure for the diagnosis of mediastinal lymphadenopathy, especially in malignant disease. However, there are not enough data on the diagnosis of tuberculous lymphadenitis. We report a case of intra-bronchial perforation of tuberculous lymphadenitis after EBUS-TBNA. Case. A 53-year-old man admitted with continuous fever that had not responded to antibiotics. FDG/PET-CT showed mediastinal lymphadenopathy with high FDG uptake. We performed EBUS-TBNA, but the pathological result was non-specific inflammation. One week later, we tried bronchoscopy again, and recognized a mass lesion in the puncture site. After repeated biopsy of the lesion, we obtained epithelioid cell granuloma with giant cell and necrosis. Clinically we diagnosed tuberculous lymphadenitis and started anti-tuberculosis chemotherapy. Both the intra-bronchial granuloma and mediastinal lymphadenopathy improved rapidly with no recurrence. Conclusion. We should pay attention to the possibility of granulomatous perforation at the puncture site of EBUS-TBNA.

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Case. We report a 79-year-old man who had undergone right upper lobectomy for lung cancer. CT showed an enlarged nodule in the right thoracic cavity. Aspergillosis was diagnosed and he was treated with drugs, but the patient discontinued the regimen because of side effects. Hemoptysis developed and he was referred to us for surgical treatment. We performed open window thoracostomy to remove a fungus ball. Three months later, we performed latissimus dorsi flap plombage, but thoracic cavity infection occurred, and we started vacuum-assisted closure (VAC) therapy, which failed. We consider that infection control was hindered by persistent pulmonary air leakage, and performed bronchial occlusion using endobronchial Watanabe spigots (EWS). We performed pectoralis major flap plombage 11 weeks later, and he was discharged approximately 10 months after the first operation. Conclusion. The bronchial embolization using EWS was very effective in this case to reduce pulmonary air leakage. We recommend using the EWS before surgical treatment of empyema with intractable fistulas.

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Background. Bronchial arterial embolization (BAE) and/or surgery are standard therapies for massive hemoptysis. Some cases of hemoptysis treated with endobronchial Watanabe spigot (EWS) have been recently reported. Case 1. A 60-year-old man with a history of frequent hemoptysis due to pulmonary aspergillosis since 7 years previously was transferred to our hospital due to massive hemoptysis. After admission, his respiratory condition worsened because of further bleeding and hemoptysis; urgent BAE was carried out but bleeding did not stop. A fiberoptic bronchoscopy study showed that the bleeding originated from the right upper lobe. EWSs were used to occlude the right B^1, B^2 and B^3. We found bleeding from the middle lobe 6 days later, and added EWSs to occlude right B^4 and B^5. This treatment successfully controlled hemoptysis and cough. Case 2. An 80-year-old woman was referred to our hospital because of hemoptysis. After admission, an urgent BAE was performed to stop the massive hemoptysis and progressive dyspnea but this treatment failed to stop bleeding. EWSs were placed in right B^4 and B^5 through bronchoscopy under local anesthesia and this treatment controlled the hemoptysis. Mycobacterium avium was identified in sputum culture. Conclusion. EWSs can be effective to control massive hemoptysis after unsuccessful BAE.

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Case. A 68-year-old man presented with hemoptysis. A chest computed tomography (CT) examination performed at a previous hospital showed a mass in the left upper lobe (S^3) with direct invasion to the anterior mediastinum, 48×46mm in size. The patient was referred to our hospital for the evaluation of an abnormal shadow. Tumor markers were negative. A bronchoscopic examination was performed, and a white polypoid lesion in the left superior segment bronchus was discovered. A definitive diagnosis of the biopsy specimen obtained from this tumor revealed a thymoma. A thymothymectomy, a left upper lobectomy and a pericardiectomy were performed. The surgical specimen was found to be a type B1 thymoma, and the tumor had extended not only to the mediastinum, but also to the pulmonary parenchyma with polypoid growth into the bronchial lumen. Conclusion. Cases of invasive thymoma with endobronchial growth are rare, but the possibility of a thymoma should be considered in cases with endobronchial polypoid growth.

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Background. Bronchofiberscopic ethanol injection (BEI) therapy was reported to be useful treatment for obstructive lesions of central airways. Case. A 59-year-old man, complained of bloody sputum and mild dyspnea 2 months after resection of lung cancer. Bronchofiberscopic findings revealed two large polypoid tumors based on the palatine tonsil and on the lingual tonsil. The airway obstruction had occurred due to obstruction of the epiglottis by the tumors. The tumors were diagnosed as metastatic tumors of lung cancer by biopsy. We performed intratumoral injection of 99.5% ethanol via a bronchofiberscope for the tumors in the oral cavity. The tumors in the oral cavity disappeared after BEI therapy and recurrence of the tumors was not observed during the approximately 5 months until his death due to lung cancer. Conclusion. BEI therapy was thought to be very effective for polypoid tumors protruding into the airway and to contribute to the quality of life of patients.

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Background. We report a bronchial foreign body consisting of a V-shaped fish bone which flexible bronchoscopic removal was difficult. Case. A 75-year-old man presented at another hospital complaining of laryngopharyngeal discomfort cough and bloody sputum. He was referred to our hospital with a diagnosis of a bronchial foreign body in the left main bronchus on chest computed tomography. Six weeks previously, he had a fit of coughing while ingesting sea bream soup. Flexible bronchofiberscopic examination showed a V-shaped fish bone in the left main bronchus (longer axis 2.5cm, shorter axis 1.5cm). We grasped the shorter part of the V-shaped fish bone with alligator forceps and tried to remove it. However, it was difficult to remove it, because the longer axis of the V-shaped fish bone exceeded the length of the bronchial lumen diameter. After that, we grasped the long part of V-shaped fish bone with the alligator forceps and removed it successfully. Conclusion. Clinicians can generally remove needle-like fish bones relatively easily by flexible bronchoscopy. However, if the fish bone is V-shaped, it can become difficult to remove it when one side is long and the angle is wide. In such cases, clinicians should consider the indications of rigid bronchoscopy or surgical operation.

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Background. Bronchial atresia is relatively rare and its frequency is lower in the left lower lobe than in other lobes. Cases. One patient was a 28-year-old woman whose three-dimensional reconstruction images of bronchi suggested obstruction of left B^<10>. The other patient was a 69-year-old man. Three-dimensional reconstruction images suggested obstruction of left B^8b. Bronchoscopic examination revealed obstructions of left B^8bi and B8^bii, respectively. In both cases, chest CT showed a tumor surrounded by emphysematous changes of the peripheral lung fields. Conclusion. Mucoid impaction of the bronchi and hyperlucency are characteristic findings of bronchial atresia on chest CT. Three-dimensional reconstruction images are useful for its diagnosis.

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