Background. Bronchoscopy is used in many procedures, such as endoscopic ultrasonography, tracheal stent placement, placement of Endobronchial Watanabe Spigots, and preoperative coil marking. However, bronchoscopy is a complicated procedure, and breakage can occur due to external forces. Bronchoscope breakage is associated with both adverse economic effects and patient-related consequences, since these devices are expensive and their breakage may increase the rates of complications and cause interruptions in examinations and treatments, if repairs are necessary. Purpose. We considered the causes of bronchoscope damage at our hospital in order to design future preventive measures and precautions. Method. We examined the bronchoscope type, their breakage status, and the repair costs for the 246 bronchoscopes in our department between January 2015 and November 2017. Result. A bronchoscope was damaged in 3 of the 246 cases, resulting in a damage rate of 1.2%. Damage to the bronchoscope occurred during yttrium-aluminium-garnet laser resection (n=2) because of thermal damage to the suction forceps port, during a right upper lobe biopsy (n=1) because of the forceps contacting the curved part, and during an endobronchial ultrasound lymph node biopsy because of damage to the tube caused by the puncture needle (n=1). Conclusion. All cases of breakage occurred secondary to technical factors owing to a lack of understanding of the structure of the bronchoscope and procedural instability. Bronchoscope damage increases expenses and procedural time while potentially reducing safety. The bronchoscopy procedure must be improved. Furthermore, practitioners should increase their understanding of the bronchoscope structure in order to prevent damage. Precautionary measures can be communicated through short lecture courses and education programs in order to increase practitioners' understanding of the internal structure of the bronchoscope and measures to increase procedural stability.

Background. The treatment of lung abscess and infectious pulmonary bullae usually requires long-term antibiotic therapy, mainly due to the lack of a safe and easy drainage technique. Transbronchial drainage using the endobronchial ultrasonography and guide sheath (EBUS-GS) technique may be useful for the drainage of infectious lesions in the lung. Methods. We retrospectively analyzed data from the medical records of patients with lung abscess or infectious pulmonary bullae treated with transbronchial drainage using the EBUS-GS technique. Results. Between September 2016 and February 2020, we found seven cases, including four cases of lung abscess and three of infectious pulmonary bulla. In six of the cases, a guide sheath was inserted into the infectious lesion, and transbronchial drainage was performed successfully. The amount of drained pus was 5-50 ml. The infectious lesions reduced rapidly after drainage. In two of the six cases, anaerobic bacteria were detected in the pus culture. Conclusion. Transbronchial drainage by EBUS-GS may be useful for the treatment and detection of pathogens in lung abscesses and infectious pulmonary bullae.

Background. The difference in the efficacy and safety of pethidine hydrochloride alone (P group) and pethidine combined with midazolam (M+P group) for bronchoscopic sedation is unclear. Methods. We used a questionnaire to investigate the tolerability of reexamination with bronchoscopy for 209 patients undergoing inpatient bronchoscopy at our hospital between September 2015 and March 2017. In this study, the patients were divided into two groups: P and M+P groups. The patients' background characteristics, diagnosis rate, complications, and questionnaire responses were reanalyzed as a post hoc analysis. Results. Of the total 209 cases, the P group comprised 81 (39%) cases, and the M+P group comprised 128 (61%) cases. Significant differences were not noted in the diagnosis rate (65% vs 73%, p=0.21) or incidence of complications (14% vs 12%, p=0.67) between the P and M+P groups. The questionnaire responses indicated that the M+P group had significantly lower levels of distress than the P group (2.2±1.1 vs 2.9±1.2, p<0.001), the procedure was less painful than expected (2.0±1.0 vs 2.6±1.3, p<0.001) and the re-examination was better tolerated (2.5±1.3 vs 3.0±1.3, p=0.010). With respect to experiencing distress during the test, a greater number of respondents in the M+P group than in the P group stated that they were not distressed (35% vs 51%, p=0.02). Cough was cited as the most common cause of distress experienced by subjects in the P group (23%), while many subjects in the M+P group listed the pre-examination pharyngeal anesthesia as a cause of distress (29%). Conclusion. The tolerability and safety of sedation using a combination of midazolam and pethidine in bronchoscopy are similar to those of midazolam and fentanyl sedation reported previously in a prospective intervention study in Japan; thus, the use of a combination of midazolam and pethidine is considered a powerful sedation method.

Background. Psoriasis is a disease that causes inflammatory keratosis on the skin. It involves the mutation of genes related to the immune system, and can lead to systemic complications. Although cases of interstitial pneumonia in patients with psoriasis have been reported, the relationship between the two diseases remains uncertain. Case. The patient was a 72-year-old man who was diagnosed with psoriasis vulgaris. Chest computed tomography was performed as a screening test before the introduction of biologics. Although consolidation was found in the right lower lobe on the chest computed tomography image, other findings suggestive of bacterial pneumonia were scarce; thus, the consolidation was observed without treatment. One month later, a chest X-ray revealed that the consolidation had increased in size, and bronchoscopy was performed. Based on the pathological and clinical findings, the patient was diagnosed with organizing pneumonia. Treatment with oral prednisolone was initiated, and the shadow markedly improved. Conclusion. Psoriasis vulgaris may be complicated by organizing pneumonia. With the accumulation of further cases, the relationship between the two diseases and its etiology may be elucidated.

Background. Diffuse panbronchiolitis (DPB) is clinically diagnosed based on characteristic imaging features and an exclusion diagnosis, and long-term treatment with a 14-member macrolide is effective in most cases. However, there are rare patients in whom this treatment is ineffective. Case. The patient was 68-year-old woman diagnosed with bronchial asthma who had been treated with inhaled steroid from 40 years old. Seven months earlier, she had developed productive cough and postnasal drip, and bronchial pneumonia and sinusitis were observed on computed tomography (CT). Thus, clarithromycin therapy was started, but the symptoms did not improve. After six months, centrilobular nodular opacities in both lower lobes were newly observed on chest CT. Therefore, roxithromycin therapy was started in consideration of the possibility of DPB. However, the dyspnea progressed and oxygen therapy was started. A transbronchial lung biopsy was performed and revealed pathological findings of DPB with active inflammation. She was treated with azithromycin, and her symptoms and centrilobular nodular opacities on chest CT improved. Conclusion. A transbronchial lung biopsy was useful for distinguishing 14-member macrolide-resistant DPB complicated with bronchial asthma from other diseases.

Background. Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by alveoli filled with PAS-positive surfactants and phospholipids. We herein report an immunosuppressive patient with secondary PAP who was successfully treated by segmental bronchoalveolar lavage (BAL) without any complications. Case. A 54-year-old Japanese man was admitted to our hospital because of a cough during immunosuppressive therapy for Takayasu's arteritis and was hospitalized for suspected acute interstitial pneumonia based on chest X-ray and computed tomography (CT) findings of ground-glass opacities in both lung fields. Broad-spectrum antibiotics, antifungal drugs, and corticosteroids were ineffective, and the diagnosis of PAP was made by a thoracoscopic lung biopsy. Following segmental BAL, his respiratory condition and ground-glass opacity in both lung fields improved with no recurrence. Conclusion. Although whole-lung lavage under general anesthesia is often used as a standard treatment for alveolar proteinosis, even in cases of immunosuppressed hosts with secondary alveolar proteinosis, such as the present patient, segmental BAL is used. A comprehensive approach that includes segmental BAL is necessary.

Background. Multifocal micronodular pneumocyte hyperplasia (MMPH) is a pulmonary manifestation of tuberous sclerosis complex (TSC). However, there are reports on the diagnosis of TSC based on presence of MMPH. Case. The patient was a 46-year-old woman with a 10-year history of multiple ground glass opacities (GGOs) in both lung fields, although she had not been followed-up for a number of years because there had been no significant change in her GGOs. GGOs had recently been pointed out on computed tomography performed for an unrelated reason and a bronchoscopic examination was performed with biopsy of the area of GGO. A histopathological examination of the biopsy specimen showed the proliferation of type II alveolar epithelial cells. This finding was suggestive of MMPH, and a clinical diagnosis of TSC was made based on a physical examination and imaging studies. Genetic testing identified a mutation of the TSC1 gene. Conclusion. We reported a case of TSC that was diagnosed based on the detection of multiple GGOs, for which a bronchoscopic examination was useful. This case indicates the importance of considering MMPH in the differential diagnosis of patients who present with multiple GGOs.

Background. There are few reports of endoscopic treatment for late-onset bronchopleural fistula (BPF). Case. A man in his sixties underwent right lower lobectomy and mediastinal lymph node dissection for squamous cell carcinoma (pT3N1M0, stage IIIA), followed by 4 cycles of adjuvant chemotherapy with carboplatin and gemcitabine. A chest X-ray revealed an air-fluid level around the edge of the bronchial stump 6 months after the operation. Bronchoscopy demonstrated a fistula of approximately 3 mm in diameter and 20 mm in depth, and the patient was diagnosed with late-onset BPF. The fistula was occluded with 2 polyglycolic acid sheets presoaked in fibrin glue. One was placed at the bottom of the fistula, and the other was placed at the entry of the fistula. The BPF was considered to have been curatively treated after observing the occlusion mesh for 3 weeks after the procedure. Conclusion. We propose that endobronchial closure of late-onset BPF using fibrin glue and polyglycolic acid sheets is useful.

Background. Bleeding is one of the major complications of bronchoscopy, and sometimes requires intensive airway protection. Case. A 52-year-old woman underwent a transbronchial lung biopsy for bilateral ground glass opacities. The biopsy induced severe bleeding, and hemostasis could not be achieved by bronchoscopy. We therefore performed intubation and initiated mechanical ventilation. Although we temporarily succeeded in controlling the bleeding and stabilizing the patient's respiratory condition, blood clots suddenly obstructed the airway twelve hours after bronchoscopy. We extracted the blood clots by bronchoscopic suctioning. We then placed a bronchial blocker to prevent repeated incidences. Two days later, we confirmed hemostasis and removed the bronchial blocker. The patient was extubated eight days later. The patient did not experience recurrence of airway obstruction by blood clots thereafter. We considered the ground glass opacities had been caused by Pneumocystis pneumonia. Her condition improved on treatment with sulfamethoxazole/trimethoprim and prednisolone, and she was subsequently discharged. Conclusion. When severe bleeding occurs during bronchoscopy, the patient should be carefully examined for blood clots and central airway obstruction. A bronchial blocker may be useful for preventing recurrence in such cases.

Background. Metallic stents are useful for managing malignant central airway stenosis. Recently, the metallic tapering stent was reapproved as palliative treatment for malignant central airway stenosis. Case 1. A 60-year-old man underwent chemotherapy for advanced esophageal cancer, but airway narrowing occurred from the carina to bronchus intermedius. A spiral relief stent (Cosmotec Co., Ltd., Tokyo, Japan) with an inner diameter of 12/18 mm and length of 80 mm was implanted from the right main bronchus to the middle trunk using a rigid bronchoscope. Case 2. A 74-year-old man underwent radiation therapy for lung cancer at the right upper lobe. Fifteen months after radiation therapy, tumor invasion was identified from the bronchus to the middle trunk. Argon plasma coagulation and core out with a rigid bronchoscope was performed under general anesthesia, and airway patency was maintained. He underwent chemotherapy with immune checkpoint inhibitor; however, restenosis occurred due to tumor growth. A spiral relief stent with an inner diameter 12/18 mm and length of 80 mm was implanted from the right main bronchus to the middle trunk. Conclusion. A metallic tapering stent was effective for managing malignant central airway stenosis, including the carina.

Background. Legionella pneumonia-when not properly treated-is associated with a high rate of mortality; thus, an early diagnosis and treatment are critical. In some cases, however, an early diagnosis may be difficult to make. Case. A 53-year-old Japanese man who visited a local hospital with a chief complaint of fever, was diagnosed with bacterial pneumonia and was given ceftriaxone; however, his condition did not improve. He was therefore transferred to our hospital for treatment. The initial antibiotic treatment failure and chest CT imaging suggested organizing pneumonia as a probable diagnosis. In order to distinguish between bacterial infection and organizing pneumonia, we performed bronchoalveolar lavage (BAL) soon after his arrival at our hospital. We could not perform a Legionella urinary antigen test because we could not obtain a urine sample. Thus, we performed the Legionella antigen test using bronchoalveolar lavage fluid (BALF) as a substitute for urine on a trial basis. Based on the positive test result, we suspected legionella pneumonia. The diagnosis of legionella pneumonia was subsequently confirmed by the analysis of a urine sample using a Legionella urinary antigen test. We immediately started treatment with levofloxacin and azithromycin. He made a good recovery and was discharged on the ninth hospital day. Conclusion. When a urine sample cannot be obtained in a case of suspected legionella pneumonia, BALF can be substituted for urine for the Legionella urinary antigen test.

Background. Lymphangioleiomyomatosis (LAM) is a slowly progressing disease in which smooth muscle-like tumor cells (LAM cells) proliferate and form multiple cysts in the lung. The selection of a pathological diagnostic method corresponding to each case is necessary. Case Presentation. A 46-year-old woman was diagnosed with bronchial asthma in her 20s. She was referred to our hospital for close examination due to aggravation of respiratory distress. On chest CT, multiple cysts of 8-12 mm in diameter with a thin wall and clear boundary were present throughout the entire lung field and LAM was suspected. Since severe obstructive ventilatory impairment (forced expiratory volume % in 1 second: 24.08%) was observed, transbronchial lung cryobiopsy was selected as a minimally invasive highly sensitive diagnostic method. Results. Cryobiopsy could be performed without complication. Histopathologically, smooth muscle-like spindle cells proliferated in a macular pattern in spaces with small cystic dilation and around blood vessels in the alveolar region, which was consistent with a diagnosis of LAM. Conclusion. Cryobiopsy is considered a useful diagnostic method for suspected LAM in patients with a reduced respiratory function.

Background. A bronchial foreign body (BFB) can cause chronic coughing. The misdiagnosis of a BFB consisting of a crab claw tendon as bronchial asthma is unusual. Case. An 82-year-old man with chronic asthma was admitted to another hospital due to pneumonia. Computed tomography revealed a BFB in the left main bronchus. The patient habitually ate crab claws and had unknowingly aspirated part of one. He had been treated as an asthma patient for some time; however, a flexible bronchoscopic examination revealed that a crab claw tendon had deeply penetrated the bronchial mucosa in the left main bronchus. The BFB was extracted using a flexible bronchoscope and microwave coagulation therapy (MCT), and his chronic cough diminished immediately post-removal. Conclusion. Flexible bronchoscopy and MCT were successfully used to safely remove a crab claw tendon, eliminating asthmatic symptoms.

Background. Schwannoma originates from the Schwann cells and can occur in any part of the peripheral nerve. Schwannomas of the lungs, trachea, bronchi, and mediastinum are rare. We report 2 cases of schwannoma that were diagnosed by bronchoscopy. Case Descriptions. Case 1: A 69-year-old man was referred to our hospital due to an abnormal shadow in the chest. Chest computed tomography (CT) revealed the presence of a 41-mm tumor, which was adjacent to the left tracheal margin in the upper mediastinum. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed. A pathological examination demonstrated the presence of spindle cells with a palisading pattern. Immunohistochemical staining was positive for anti-S-100 antibodies. The patient was therefore diagnosed with mediastinal schwannoma. We performed tumor resection because the trachea was displaced. Case 2: The patient was a 48-year-old man who was being treated for another disease. Chest CT for screening revealed the presence of a 10-mm tumor in the membranous portion of the trachea. We performed a transbronchial biopsy. A pathological examination revealed the presence of spindle cells proliferating in a wave-like pattern. Immunohistochemical staining was positive for anti-S-100 antibodies. The patient was therefore diagnosed with tracheal schwannoma. Since the tumor was small and the patient had no airway obstruction symptoms, careful follow-up was performed based on the patient's wishes. Conclusion. Intrathoracic schwannomas were previously histopathologically diagnosed using surgical specimens. In some cases, they can now be diagnosed by appropriate bronchoscopy.

Background. Drug-induced lung injury caused by Hachimijiogan is rare. Case. A 70-year-old man with no history of respiratory disease developed ventricular fibrillation in early August 20XX-1 and was treated with 200 mg/day of amiodarone in the cardiology department of our hospital. In addition, the urology department of our hospital prescribed him 7.5 g/day of Hachimijiogan for benign prostatic hypertrophy. He began to experience cough by late August and dyspnea on exertion by mid-September and was admitted a short while later. Computed tomography revealed ground-glass opacity and consolidation in the peripheral areas of both lung fields. A cytologic analysis of the bronchoalveolar lavage fluid revealed a predominantly eosinophilic cell fraction with no foamy macrophages. A lymphocyte stimulation test showed positive results for Hachimijiogan. We therefore diagnosed the patient with drug-induced lung injury due to Hachimijiogan. Conclusion. We herein report a case of eosinophilic pneumonia caused by Hachimijiogan in which bronchoalveolar lavage was useful for differentiation from pulmonary amiodarone toxicity. Drug-induced lung injury caused by Hachimijiogan is rare, and there have been no previous reports of the disease.