Background. Although bronchoscopy can be very helpful in the diagnosis of diffuse lung diseases, the hypoxemia during the procedure often becomes a problem. Conventionally, oxygen supplementation using a nasal cannula or noninvasive positive pressure ventilation (NPPV) was performed in hypoxemic patients. However, a nasal cannula has the limitations in delivery of oxygen, and the NPPV mask disturbs bronchoscopic manipulation and comfortable breathing for patients. In some patients, therefore, we are not able to perform bronchoscopy safely. The usefulness of a high-flow nasal cannula (HFNC) during bronchoscopy of diffuse lung diseases has not yet been reported. Objective. The aim of this study was to evaluate the tolerability and usefulness of HFNC in diffuse lung disease patients with acute respiratory failure undergoing bronchoscopy. Methods. Sixteen hypoxemic patients who underwent bronchoscopic examination using the HFNC were retrospectively analyzed. We retrospectively evaluated 16 patients who underwent bronchoscopic examination using the HFNC. These patients had undergone bronchoalveolar lavage (BAL) and/or transbronchial lung biopsy (TBLB) to diagnose diffuse lung disease from December 2012 to April 2015. Results. The median period from the first visit to conducting bronchoscopy was 2 days. In 15 out of 16 patients, bronchoshopy using the HFNC was tolerable, and no remarkable oxygenation problems were observed during the examination. We performed BAL in 13 patients and TBLB in 6 patients. There was no procedural complication when using HFNC. In all patients, we obtained useful information which directly or indirectly contributed to the clinical diagnosis. Conclusion. The HFNC can be employed safely and effectively and is useful in diffuse lung disease patients with acute respiratory failure undergoing bronchoscopy. It is still unclear regarding the patient selection criteria, such as the severity of hypoxemia, characteristics of patients etc.. Further investigations are warranted to evaluate the usefulness of HFNC in bronchoscopic examinations.

Background. Pleural sarcoidosis is a rare disease. Here, we report a case of pleural sarcoidosis in which the thoracoscopic findings, under local anesthesia, mimicked carcinomatous pleurisy. Case. A woman in her 70s was found to have mediastinal lymphadenopathy in a medical examination. Multiple lymph nodes showed ¹⁸FDG accumulation on PET. Thoracoscopy under general anesthesia revealed sarcoidosis. She was referred to our hospital about a month later. Chest X-ray showed pleural effusion on the right side. The pleural effusion was exudate. Thoracoscopy under local anesthesia was performed. On the parietal pleura, granular polypoids, small nodules, and capillary dilatations were observed. Touch imprint cytology revealed atypical cells suspicious of adenocarcinoma, suggesting carcinomatous pleurisy. These findings indicated that lymphadenopathy may be caused by a sarcoid reaction other than sarcoidosis. However, there were no lesions in other organs. Bronchoscopic findings were consistent with a diagnosis of sarcoidosis. A pathologic analysis of the pleural biopsy revealed non-caseous granulomas, and multinucleated giant cells. However, no neoplastic cells were found. We finally concluded that the pleural effusion and pleural lesions were caused by pulmonary sarcoidosis. Conclusion. It is important to know that thoracoscopic findings of pulmonary sarcoidosis can be similar to those of carcinomatous pleurisy.

Background. Endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is useful for diagnosis of pleural and mediastinal neoplastic lesions adjacent to the esophagus. Case. A 70-year-old man was referred to our hospital for evaluation of fever and cough. Chest CT scan showed multiple pleural tumors (maximum size, 50 mm) in the right thoracic wall. FDG-PET revealed abnormally increased FDG uptake in the tumors. A lung cancer with dissemination or malignant pleural mesothelioma was suspected. The tumors were not adjacent to the airways but were adjacent to the esophagus, so we performed a biopsy through the esophagus using an endoscopic ultrasound with a bronchoscope (EBUS) to diagnose them. Histologic examination showed eosinophilic epithelial atypical cell clusters, and immunohistochemical staining of epithelial atypical cells was positive for calretinin and WT-1, and negative for CEA and Ber-EP4. We performed pleuroscopic pleural biopsy to obtain a specimen that contained all layers of the pleural tumor with fat. The final diagnosis was epithelioid malignant pleural mesothelioma. Conclusion. We could obtain a good quality and adequate specimen for diagnosing epithelioid malignant pleural mesothelioma. EUS-B-FNA is useful for the diagnosis of epithelioid malignant pleural mesothelioma adjacent to the esophagus.

Background. The diagnostic rate of pulmonary actinomycosis by bronchoscopy is reportedly low. Case. A 62-year-old woman complained of bloody sputum, which had started three weeks before admission to a neighborhood hospital. Chest computed tomography (CT) indicated a mass in the right upper lobe, and the patient was referred to another hospital. Bronchoscopy was performed but was not contributory in making a diagnosis. The bloody sputum persisted and the mass on CT enlarged. She was then referred to our hospital. She had untreated dental caries and diabetes. CT revealed a mass with central low attenuation areas, raising the possibility of pulmonary actinomycosis in the differential diagnosis. To collect a specimen from the central part of the mass, bronchoscopy using endobronchial ultrasonography with a guide-sheath (EBUS-GS) method was performed. Brushing cytology revealed sulfur granules characteristic of actinomycosis. Conclusions. The suspicion of pulmonary actinomycosis necessitated collection of a specimen from the deep part of the lesion. Bronchoscopy by the EBUS-GS method was useful for making the diagnosis.

Background. Pulmonary alveolar proteinosis (PAP) is caused by abnormal intra-alveolar accumulation of surfactant protein, and the treatment of PAP is whole-lung lavage. Case. A 47-year-old Japanese man started to have progressive exertional dyspnea and nonproductive cough, and the diagnosis of PAP was made according to radiological, laboratory and pathological findings of bronchoalveolar lavage (BAL) fluid and transbronchial lung biopsy. Then he was admitted to our hospital for PAP treatment. Lingular segmental and subsequent right middle lobe BAL therapy were performed. Chest roentgenogram and computed tomography (CT) showed an improvement of bilateral lower lobes that had not been treated in addition to the treated areas. Conclusion. Segmental BAL therapy was effective not only in lavaged areas but also non-lavaged regions, therefore, segmental BAL therapy can be an alternative treatment modality in addition to total lung lavage therapy for treating patients with PAP.

Background. Bronchopulmonary actinomycosis is a rare disease known to be caused mainly by foreign matter. The removal of this foreign matter via long-term antibiotic administration is critical for its successful treatment. Case. A 74-year-old male had advanced-stage lung cancer. The right bronchus intermedius was blocked by the tumor, leading to respiratory failure. A tracheobronchial metal stent was placed to treat this condition. However, five years after placement, the condition was complicated by development of bronchopulmonary actinomycosis at the stent placement site. Antibiotics were ineffective, so the airway stent was removed with biopsy forceps to alleviate the patient's hypoxemia. Results. The bronchopulmonary actinomycosis was eventually cured, and antibacterial therapy was provided. The patient experienced no recurrence over a one-year follow-up period. Conclusion. Removal of the offending foreign matter is critical for the treatment of bronchopulmonary actinomycosis, as reported previously. However, in the present case, removal of the tracheobronchial metal stent carried a risk of severe bleeding and mucosal damage. The removal of such sensitive material therefore needs to be approached carefully.

Background. Recanalization of tracheoesophageal fistula in congenital esophageal atresia has been reported even after surgical treatment. Case. A 35-year-old woman who was admitted to our hospital for further examination of bronchiectasis, had undergone surgical treatment of congenital esophageal atresia in the neonatal period. She had suffered from refractory pneumonia after high school. Chest X-ray film showed infiltrative shadow with air fluid levels in the left lower lung field. Chest CT showed bronchiectasis with retention of fluid and bronchopneumonia in the left lower lobe. Bronchoscopy showed leakage of fluid from a fistula in the membranous portion of the trachea. We speculated on the possibility of the recanalization of the tracheoesophageal fistula. Endoscopy also showed fistula in the anterior esophageal wall and esophagography showed the fistula communicating between the trachea and the esophagus. We diagnosed recanalization of the tracheoesophageal fistula and treated by fistulectomy after antibiotic treatment for bronchopneumonia. It was suggested that repeated intratracheal aspiration through the fistula caused refractory bronchopneumonia, leading to bronchiectasis in the left lower lobe. Conclusion. In cases of bronchiectasis with refractory bronchopneumonia who had previously been treated for congenital esophageal atresia in the past, we should suspect recanalization of tracheoesophageal fistula.

Background. Malignant pleural effusions are rare clinical findings of prostate cancer. Here, we report a case of prostate cancer that was diagnosed because of thoracoscopy under local anesthesia. Case. An 86-year-old man presented with cough, dyspnea on exertion, and weight loss. Computed tomography of the chest showed right pleural mass lesions with pleural effusions. We performed thoracoscopy under local anesthesia; smooth mass lesions of various sizes were observed on the parietal pleura, and a biopsy examination revealed pleural metastasis of prostate cancer. Endocrine therapy was started based on the diagnosis. Conclusion. We encountered a case of prostate cancer diagnosed because of pleural effusion detected on thoracoscopy under local anesthesia. Prostate cancer should be considered when pleural effusions are observed in older men on thoracoscopy.

Background. When treated with antibiotics, infected emphysematous bulla results in improved symptoms in general, however, complications may occur in cases in which drainage fails. Case. A 76-year-old man with infected emphysematous bulla was administered antibiotics for about 6 weeks, which led to no improvement. Because a connection between the bronchus and the bulla was detected by bronchoscopy and X-ray fluoroscopy, bronchial occlusion was performed at the site of the connection and a chest drainage tube was inserted percutaneously into the bulla. Results. Irrigation with saline through the drainage tube over several consecutive days resulted in a decreased abscess in the bulla and diminished inflammatory response. After adhesion of the bulla using autologous blood, the drainage tube was removed. Conclusion. Percutaneous drainage and irrigation with saline under bronchial occlusion are very useful treatments for infected emphysematous bulla when antibiotics do not provide an adequate response, since bronchial occlusion can prevent spread of inflammation to other lung lobes and pneumothorax.

Background. Pulmonary mucoepidermoid carcinoma (MEC) is a rare disease, and its prognosis is dependent on its grade. Case 1. A 58-year-old woman underwent a right upper lobectomy for lung adenocarcinoma, however a postoperative pathological report revealed the tumor was low grade MEC. She has been free of recurrence for two years. Case 2. A 35-year-old woman underwent a medical checkup, and a tumor at the left pulmonary hilum was found. This tumor was diagnosed as high grade MEC with lymph node metastasis. A left pneumonectomy was performed. Thereafter, postoperative recurrences were found in bone and cervical lymph nodes. Conclusion. It used to be difficult to diagnose MEC, but recent reports showed almost 60% cases had correct diagnoses by bronchoscopic examination. Moreover about 70% of those diagnosed cases were low grade MEC, that could be cured by complete resection. However, the prognosis of high grade MEC is poor. We need to investigate more effective multimodality treatment for high grade MEC.

Background. Bronchopleural fistula is one of the most serious complications of pulmonary resection. Case. An 80-year-old woman underwent left lower lobectomy for metastatic lung cancer. Ten months after the operation, she was admitted to our hospital due to suspected bronchopleural fistula with empyema. She was found to have a bronchopleural fistula by bronchoscopy. Endoscopic sclerotherapy by a submucosal injection of polidocanol around the fistula was performed. The air leak stopped two days after the sclerotherapy, and the fistula was closed one month after the sclerotherapy. The empyema was treated by pleural lavage and drainage. The chest tube was removed four weeks after sclerotherapy, and the patient was discharged. Ten months thereafter, the patient has shown no sign of recurrent bronchopleural fistula. Conclusion. Endoscopic submucosal injection of polidocanol around a bronchopleural fistula is technically easy, minimally invasive and effective procedure.

Background. We report a case of progressive emphysematous giant bullae treated with intrabulla suction followed by bronchoscopic bronchial occlusion using an Endobronchial Watanabe Spigot (EWS) and intrabulla injection of fibrin glue. Case. A 70-year-old man entered another hospital with a primary complaint of severe progressive dyspnea. Chest computed tomography (CT) showed progressive enlargement of right emphysematous giant bullae over time, which compressed the remaining normal lung. He had previously been treated with right pneumothorax three times, and was then found to have left lung cancer with malignant pleural effusion. To inflate the remaining normal lung, he underwent CT-guided intrabulla suction using a 14 Fr catheter under local anesthesia. Afterwards, he underwent additional bronchoscopic occlusion using EWS and intrabulla injection of fibrin glue due to continuous air leakage. Conclusion. We successfully treated this case without surgery because of the patient's poor performance status and the complications of contralateral lung cancer.