Background. Although bronchoscopy is an essential test to examine respiratory diseases, it can be suspended due to severe hypoxemia. The most commonly used oxygen delivery devices are nasal cannula and oxygen mask. Noninvasive positive pressure ventilation (NPPV) and high-flow nasal cannula (HFNC) have been introduced recently to oxygen therapy during bronchoscopy, and previous studies have shown that both devices are superior to nasal cannulas and oxygen masks in cases of adult patients with acute respiratory failure. It has not been reported yet that Jackson mask ventilation is useful and safe when adult patients with acute respiratory failure undergo bronchoscopy. Objective. The aim of this present study is to assess the usefulness and safety of using Jackson mask ventilation in adult patients with respiratory failure either before or during bronchoscopy. Methods. We retrospectively reviewed the records of patients who underwent bronchoscopic procedures with Jackson mask ventilation from June 2014 to December 2016 at the Department of Respiratory Medicine, National Center for Global Health and Medicine, Japan. Results. Bronchoscopic procedures with Jackson mask ventilation were done in 7 adult patients and were completed successfully without any severe complications apparently related to Jackson mask ventilation. We performed bronchoalveolar lavage (BAL) in 5 patients, transbronchial lung biopsy (TBLB) in 5 patients and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in 1 patient, and removed blood clots in 1 patient. A total of 7 bronchoscopic biopsies provided clinical information which contributed to diagnoses and treatments. Conclusion. The application of Jackson mask ventilation during bronchoscopy to patients with acute respiratory failure was feasible. Further studies are necessary for evaluating the usefulness and safety of Jackson mask ventilation during bronchoscopy.

Background. Respiratory dysfunction with idiopathic scoliosis is known to be improved by orthopedic surgery. However, there are few reports of adult cases. Case. A 63-year-old woman had suffered from idiopathic scoliosis since her youth. Because of increased dyspnea with cough and sputum that had persisted for several years while sleeping at night, she underwent a medical examination. She had restrictive respiratory dysfunction, slightly elevated levels of nitric oxide in her expiration and repeated infection of the lower respiratory tract. Because of these symptoms, she was prescribed with inhaled corticosteroid/long-acting β2 agonist combination and started low-dose long-term macrolide therapy. However, these treatments were ineffective, and she was referred to our hospital. Her dyspnea while sleeping became exacerbated, particularly in the dorsal position, and was reduced in the lateral decubitus position and prone position. Chest computed tomography showed that the right intermediate bronchus was pressed flat and narrowed in front of the thoracic vertebral body. Airway stenosis due to thoracic deformity was regarded as the main cause of her symptoms. After posterior spinal fusion for scoliosis, her dyspnea, airway stenosis and respiratory function were all improved. Conclusion. Spinal fusion may be an effective treatment for airway stenosis with severe idiopathic scoliosis.

Background. It is rare for a nontuberculous mycobacterial infection to occur in the vocal cords. Case. A 72-year-old woman began to notice hoarseness in June XX. She presented to our hospital two months later. The right vocal cord showed irregularity in the laryngeal fiber. Epithelioid granulomas were detected on a biopsy of the same site, and bacterial cells stained positive on Ziehl-Neelsen staining were identified within the granulomas. Multiple granular shadows and bronchodilation were evident on chest computed tomography (CT), and Mycobacterium avium was cultured from the bronchial lavage fluid. The patient was diagnosed with nontuberculous mycobacteriosis. Chemotherapy was performed in September XX. The irregularity of the vocal cord subsequently resolved, and a repeat bronchial lavage culture for acid-fast bacteria was negative in November XX+1. Conclusion. A rare case of an abnormality of the vocal cords led to the diagnosis of nontuberculous mycobacteriosis.

Background. It is often difficult to remove long-standing bronchial foreign bodies (FB) by bronchoscopy. Case. The patient was a 76-year-old man with a medical history of impaired consciousness because of sequela of intracerebral hemorrhage and who had undergone permanent tracheotomy. He was diagnosed with pneumonia and underwent treatment in a hospital three months previously. On presentation, his chief complaint was purulent sputum and fever and he was diagnosed with pneumonia again in a hospital. A chest X-ray showed a bronchial FB in the right lower lung field. He was transferred to our hospital for the removal of the FB. The FB was found in a chest X-ray taken three months previously; thus, it was considered to be a long-standing bronchial FB. The bronchoscopic examination detected the FB as well as remarkable granulation tissue in the surrounding area; however, it was difficult to clearly visualize the FB due to the purulent secretion from an accompanying lung abscess. The purulent secretion was reduced and the granulation was diminished after antibiotic therapy. Under local anesthesia, the bronchial FB (dental prosthesis) was successfully removed without any complications by flexible bronchoscopy in combination with the use of argon plasma coagulation (APC). Conclusion. Although the long-standing bronchial FB was surrounded by remarkable granulation tissue, with the aid of antibiotic treatment and APC for cauterization and hemostasis using coagulation, the FB was safely and successfully removed by flexible bronchoscopy.

Background. Eosinophilic pneumonia following lung resection is a rare occurrence. Case 1. The first case was a 69-year-old man with non-small cell lung cancer who underwent right lower lobectomy. On postoperative day 4, CT scan showed reticular ground glass opacity in the right middle lobe, and bronchoalveolar lavage (BAL) revealed an increase in the number of eosinophils. After methylprednisolone pulse therapy on postoperative day 9, the patient showed immediate improvement in clinical and radiologic abnormalities. Case 2. The second case was a 66-year-old man with small cell lung cancer who underwent wedge resection of the left upper lobe. On postoperative day 12, the patient experienced shortness of breath on effort; subsequently, BAL revealed an increase in the number of eosinophils. Oral administration of prednisolone resulted in improvement of the radiographical findings. Conclusion. BAL is useful for the diagnosis of respiratory dysfunction in patients with interstitial pneumonia following surgery.

Case. A 54-year-old woman with dementia, who was being cared for in a facility for the elderly, was found to have difficulty while breathing owing to the presence of a piece of high-molecular weight polymer from a diaper pad in her mouth. Chest computed tomography revealed a foreign material in her trachea and the right main bronchus. Endotracheal intubation was performed, and an attempt was made to remove the foreign material using a bronchoscope. Since the high-molecular weight polymer of the diaper pad expands and becomes viscous with moisture, the suction port of the scope tended to be clogged. An attempt was made to remove the foreign material using biopsy forceps; however, as the polymer was gel-like, removal was difficult. Finally, a bronchoscope was inserted into the endotracheal tube while grasping a bronchial aspiration catheter with forceps at the tip of the scope. The aspiration catheter was introduced into the right upper lobe bronchus. The foreign material from the trachea, right main bronchus, and right upper lobe was aspirated and removed. Conclusion. Removal of a high-molecular weight polymer from the airway is rare. We intend to report on this case with some literature considerations.

Background. Sarcoidosis with atelectasis is rare in Japan. Case. A 68-year-old woman presented with dyspnea on exertion. Chest CT showed granular shadow in the bilateral upper lobes, bronchial stenosis, and right middle lobe atelectasis. Positron emission tomography-CT revealed a high fluorine-18 deoxyglucose (FDG) accumulation in the right middle lobe, so we performed a bronchoscopic examination. Bronchoscopic findings showed an obstruction at the orifice of the right middle lobe bronchus and we performed a biopsy. The tissue diagnosis was compatible with sarcoidosis. She is under careful observation as an outpatient. Conclusion. Sarcoidosis is rare as a cause of atelectasis, but should be considered.

Background. Drug-induced lung injury caused by dabigatran etexilate has been reported, such as alveolar hemorrhage, eosinophilic pneumonia; and wandering pneumonia; however, little has been reported on dabigatran etexilate-induced interstitial pneumonia in which performed transbronchial lung biopsy (TBLB) has been performed. Case. A 73-year-old man had taken dabigatran etexilate for paroxysmal atrial fibrillation. Two months later, he presented with dyspnea on exertion. His chest X-ray and CT showed bilateral ground-glass opacities. TBLB was performed, and we diagnosed dabigatran etexilate-induced interstitial pneumonia based on pathological findings of fibrosis of alveolar septa and lymphocytic infiltration. His respiratory condition and imaging findings improved with steroid semi-pulse therapy. Conclusion. Dabigatran etexilate-induced lung injury shows various findings, and TBLB was useful in the diagnosis.

Background. Bilateral airway foreign bodies are rare, but easily lead to respiratory failure, and thus should be treated quickly. We reported a case of bilateral airway foreign bodies due to some pieces of apple successfully removed by the flexible bronchoscope. Case. A 71-year-old man who suffered cerebrovascular disease, lapsed into dyspnea while he was eating some pieces of apple cut to 2 cm in size. He was sent immediately to our hospital. Chest computed tomography showed foreign bodies in the right and left bronchus. We put him on sedation and under ventilator control. We removed two pieces of apple successfully using a grasping forceps, basket type grasping forceps, aspiration needle, gastrointestinal endoscope balloon and a flexible bronchoscope. Conclusion. Since cases of tracheal foreign body are limited, it is important to carefully examine each case concerning the methods of CT, securing the airway, anesthesia management, and removing foreign bodies. When encountering a new case, taking advantage of those experiences, we should choose appropriate equipment and anesthesia management to remove bilateral airway foreign bodies immediately.

Background. Primary tracheobronchial amyloidosis is a rare disease, but some cases coexisting with systemic disease have been reported. Case. A 58-year-old woman was referred to our hospital because of chronic cough that had occurred during the treatment of fibromyalgia, systemic scleroderma, and Sjögren syndrome. Chest CT showed bronchial wall hypertrophy and stenosis with calcification localized to the left B³, left B⁸, and right B⁷ central side. Trans-bronchoscopic bronchial biopsy revealed AL amyloid deposit in the lesion, and thus we diagnosed tracheobronchial amyloidosis. Previous reports in search results of the Japan Medical Abstracts Society showed that approximately 17% of primary tracheobronchial amyloidosis had some coexisting systemic diseases, mostly including Sjögren syndrome. Conclusion. Amyloid deposition in the respiratory tract mucosa may be related to some systemic diseases.

Introduction. We herein report an autopsy case of acute massive hemoptysis due to broncho-aortic fistula caused by Actinomyces infection of a bronchial self-expandable metallic stent (SEMS) in a patient with unresectable lung cancer. Case. A 64-year-old man presented with persistent cough. Chest computed tomography (CT) scan demonstrated a left hilar mass. Bronchoscopy revealed an endobronchial tumor obstructing the left main bronchus. The biopsy of the tumor revealed squamous cell carcinoma. The day after the bronchoscopy, the patient suddenly developed respiratory failure due to left total atelectasis. Thus, a SEMS was placed by a flexible bronchoscopy, as emergency treatment. Carboplatin plus S-1 was started under the diagnosis of clinical T4N1M0 stage IIIA disease. He complained of dysphagia and fever after 3 cycles of the chemotherapy. Chest CT showed esophagobronchial fistula, and another SEMS was additionally placed in the esophagus and the symptoms improved. After that, only S-1 maintenance therapy was continued to avoid further tumor necrosis. After 5 months from the diagnosis, he was transferred to our hospital for acute massive hemoptysis; however, he had suffered out-of-hospital cardiopulmonary arrest. Autopsy demonstrated broncho-aortic fistula in the left main bronchus, in which Actinomyces infection was evidenced by pathological examination.

Background. It is sometimes difficult to approach the caudal bronchus in the left superior segment of the lung by usual insertion techniques. Case. A 70-year-old man was admitted to our hospital because of a nodular shadow that had been detected on chest computed tomography (CT). Although CT revealed a tumor shadow in the left S³, the lesion was not diagnosed by CT-guided biopsy. We detected an irregular white-like epithelial lesion at the left B³biβx using a 2.8-mm ultra-thin flexible bronchofiberscope, which was identified based on the anatomy observed on CT. We also attempted to approach the lesion using a 4.0-mm thin flexible bronchofiberscope; however, it was difficult to reach the left B³bi. After turning the scope 180 degrees in the left main bronchus and using a downward angle, we easily reached the tumor in the B³bi by endobronchial ultrasonography with a guide sheath (EBUS-GS). The tumor was definitely diagnosed as squamous cell carcinoma. To confirm the effect of revolving the scope, we performed a test using a phantom model, which showed that there was a difference between the bronchoscope image obtained with normal insertion and the image obtained when the bronchoscope was rotated 180 degrees. Conclusion. Rotating the bronchoscope by 180 degrees might be useful for approaching the caudal bronchus of the left superior segment.

Background. Hemophagocytic lymphohistiocytosis (HLH) induced by tuberculosis is a comparative rare condition and the mortality is high. Case. A 70-year-old man was admitted to another hospital because of mediastinal and hilar lymphadenopathy. He underwent endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) to obtain samples of lymph nodes. A Ziehl-Neelsen stain of the needle aspirate showed the presence of acid fast bacilli. A polymerase chain reaction assay was positive for Mycobacterium tuberculosis. He was referred to our hospital for the treatment of tuberculosis. Both peripheral blood and bone marrow aspiration samples revealed the presense of hemophagocytosis. Treatment with corticosteroids and antituberculosis agents was started. The patient's general condition recovered and he was discharged 7 weeks after the start of the treatment. Conclusion. We encountered a case of tuberculosis-induced HLH. Treatment with corticosteroids and antituberculosis agents was effective. EBUS-TBNA was useful for the diagnosis of tuberculous mediastinal lymphadenopathy.

Background. Pulmonary sarcoidosis is often accompanied by infections with the Aspergillus species, but endobronchial aspergilloma is uncommon. Case. A 69-year-old man was admitted to Jichi Medical University Hospital for detailed examination of abnormal chest radiography. Chest computed tomography (CT) showed a single nodular shadow in a bronchiectatic lesion in the lingula. Bronchoscopic biopsy revealed the presence of mycelia of Aspergillus species. Thoracoscopic lingulectomy was performed. Histological examination revealed aspergilloma in the bronchiectatic lesions together with non-caseating epithelioid granulomas suggestive of sarcoidosis. The patient was observed medication-free thereafter, and no recurrences of Aspergillus infection were detected in 4 years. Conclusion. A case of endobronchial aspergilloma with sarcoidosis is reported. Aspergilloma was observed as a single nodule in a bronchiectatic lesion in the chest CT. Surgical resection was curative and the disease has not recurred.

Background. Cryptogenic organizing pneumonia (COP) should be distinguished from infectious pneumonia because of steroid treatment, and be followed with attention to opportunistic infectious complications under prolonged steroid therapy due to its high relapse rate. Case. A 77-year-old man had multiple pulmonary infiltrates resistant to antibacterial agents. The patient was clinically suspected to have organizing pneumonia and was started on steroid therapy, then the shadows resolved but frequently relapsed when treatment was tapered. Subsequently, fever, headache, and neurological symptoms developed without elevation of C-reactive protein (CRP). We diagnosed cryptococcal meningitis from cerebrospinal fluid culture, and treated it successfully with antifungal agents. Later, bronchoscopy was performed when organizing pneumonia relapsed, and the findings of transbronchial lung biopsy specimens demonstrated intraalveolar organization, although cryptococci were neither recognized in the specimens nor cultured from the bronchial lavage fluid. We therefore diagnosed his organizing pneumonia as cryptogenic. Conclusion. Clinicians should keep in mind cryptococcosis during the entire period from diagnosis to steroid therapy for organizing pneumonia, and bronchoscopy is useful for differentiating diseases.

Background. Bronchial mucoepidermoid carcinoma is a relatively rare tumor that is categorized as salivary gland-type lung carcinoma. Case. A 26-year-old man was admitted to our hospital due to hemoptysis. Computed tomography findings detected a tumor in the right upper lobe bronchus and atelectasis of the right upper lobe. Bronchoscopy revealed a smooth-surfaced tumor on the proximal side of the right upper lobe bronchus that appeared magenta on autofluorescence bronchoscopy imaging. Although transbronchial biopsy manifested no diagnostic findings, lung cancer was highly suspected. Accordingly, right upper sleeve lobectomy was performed. Subsequently, histological examination findings demonstrated low-grade bronchial mucoepidermoid carcinoma. Conclusions. We reported a young male patient who underwent complete resection of bronchial mucoepidermoid carcinoma by right upper sleeve lobectomy. Even though low-grade bronchial mucoepidermoid carcinoma has better prognosis than other lung carcinomas, careful observation is required for the detection of recurrence.

Background. Lipoid pneumonia is characterized by lipid accumulation in pulmonary lesions. Potential causes of endogenous lipoid pneumonia include airway obstruction by tumor, fat embolism, and gastroesophageal reflux disease. Case. A 75-year-old man with a history of total gastrectomy presented with ground glass shadowing of the right lower lobe on computed tomography (CT). Although it was asymptomatic, we performed bronchoscopy because the shadows persisted. The bronchoalveolar lavage fluid was yellow and lipid-laden alveolar macrophages were frequently observed. Therefore, the patient was given a diagnosis of lipoid pneumonia. Fever and dyspnea developed 20 days after bronchoscopy, and CT revealed markedly increased shadows. He was treated with corticosteroids and antibacterial drugs, and the shadows disappeared. No relapse was observed after withdrawal of corticosteroids. Discussion. In this case, silent aspiration due to esophageal reflux was suspected as a causative factor. Bronchoscopy may have temporarily promoted aspiration.