Lidocaine, a local anesthesia frequently used in bronchofiberscopy, is metabolized in the liver and excreted. The question of lidocaine toxicity during bronchofiberscopy in cases accompanied by liver diseases is important thus it is of interest to follow the blood concentration of lidocaine during bronchofiberscopy procedures. A total of 78 samples of lidocaine blood samples obtained during bronchofiberscopy were examined from 20 cases of respiratory diseases, which were classified into two groups. Group A consisted of 10 cases accompanied by liver diseases and group B consisted of 10 cases without any recognized liver disease. All patients received 2% lidocaine nebulized during the first ten minutes and lidocaine spray anesthesia to the larynx was performed for the next five minutes and then they underwent examination under instillation of anesthesia for ten minutes. Blood samples were taken at 20, 40, 60 and 120 minutes after the commencement of administration of lidocaine. There was no significant difference in the mean lidocaine doses of the two groups ; 8.58±1.33mg/kg for group A and 7.60±2.76mg/kg for group B. The mean peak concentration and the time to peak concentration showed no significant difference between the two groups. Blood levels of lidocaine continued to increase for 40 minutes after the commencement of lidocaine administration in all cases. From 40 minutes to 60 minutes, most of the group A cases, which had abnormal laboratory values in tansaminase, γ-globulin, cholinesterase, and I.C.G. level, tended to show a plateau, while most group B cases showed a downward curve. From 60 minutes to 120 minutes, the blood concentration curves tended to decrease smoothly in group A and B. We should pay particular attention to cases of liver diseases undergoing bronchofiberscopic examination, especially from 40 minutes to 60 minutes after the commencement of lidocaine administration.

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We have performed 2, 222 procedures of fiberoptic bronchoscopy (FBS) in 1985 for diagnostic or therapeutic purposes. A total of 797 bacteriological studies on bronchoalveolar lavage fluid (BALF) were undertaken, including smear tests and cultures for mycobacteria revealed a total of 86 cases of positive results for mycobacteria. We further checked and analyzed all these cases of mycobacteria-positive results and compared the results with each individual's clinical state, chest X-ray film, bronchoscopic findings, sputum bacteriology and FB scope (9 types) used, and discovered an unusually high incidence of mycobacteria false-positive results. Both fiberoptic bronchoscopes and automatic endoscope washers were found to be contaminated by atypical mycobacteria ; M. chelonae subsp. chelonae, M. chelonae subsp. abscessus, and M. gordonae. These species were frequently (73%) cultured from BALF samples of 15 cases, in which the subspecies was identified, out of 86 cases of mycobacteria-positive results, although routine sputum bacteriological examination results were negative.

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To investigate the mechanism of respiratory tract infection, we produced localized pneumonia by intrabronchial instillation of Klebsiella pneumoniae 3K-25 through a bronchofiberscope inserted into the upper lobe of rabbits. We investigated viable cell counts in the various tissues in the five pulmonary lobes, trachea and blood several times after inoculation and obtained the following results : In rabbits instilled with 2.0×10^9 CFU/rabbit, pneumonia occured only in the right upper lobe bacteriologically. Histological findings showed localized necrotizing bronchopneumonia in the right upper lobe. The results demonstrate that this model is useful for assessment of therapeutic methods and effects.

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In the past many authors have studied the main stream that bifurcates to the same size branches, ie., the parent branches in the branchial branch system. There have been some reports on the smaller branches that fill the empty spaces between the parent branches, ie., the daughter branches. But up to now, there have been few reports on the daughter branches considered from diagnosis of imaging or respiratory physiology. To determine the delineation ability of daughter branches using by bronchography, studies were done in 6 patients with primary lung carcinoma. We observed the relationships between visualization of daughter branches in hilar region of the preoperative bronchogram and eight proximal daughter branches of operated lungs in 6 these patients. (inflated-fixed by Heitzman's standard method) The following three findings were obtained ; 1) all eight daughter branches were visualized in bronchographic examination with injection of contrast medium through a bronchial catheter, whether cancerous obstruction was present or not. 2) In cases with cancerous obstruction of distal daughter branch, terminal bronchioli were visualized in bronchographic examination, but branches divided vertically were not revealed. 3) In cases without cancerous obstruction, the first or second branching in the daughter branch were visualized in bronchography. When several imagings are interpretated, existence of daughter branches must be considered.

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A 75 year-old male with emphysema complained of refractory cough and fever. Chest X-ray film revealed a pneumonia-like shadow in the right lower lobe. Fiberoptic bronchoscopy revealed a tracheal cyst and a tracheal web in the right lateral tracheal wall, 4cm below the vocal cord. Bronchography revealed single cyst in the membranous portion of the trachea. The patient was diagnosed as having congenital tracheal web associated with a congenital tracheal cyst.

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Two cases of bronchial atresia were reported. Case 1 was a 12-year-old boy without symptoms. A mass was found in the left emphysematous upper lobe on a routine chest roentogenogram. A bronchogram and bronchoscopy revealed a B^<1+2> defect. S^<1+2> segmental resection was performed. The mass consisted of mucoid material dilating the bronchi. There were no apparent connection between the left upper lobe bronchi and the dilated bronchi. Histological examination showed the dilatated bronchi to be normally developed and panlobular emphysema in the left S^<1+2> Case 2 was a 42-year-old man with a complaint of a exertional dyspnea. Chest X-rays revealed hyperlucency with a branching mass shadow in the right lower lung field. During thoracotomy, a lobulation anomaly was seen in the right lower lobe. Localized emphysema was observed in the subsuperior segment. The dilated bronchi containing mucoid material had ciliated epithelium with thin fibrous wall. There were no cartilage or bronchial glands. Including the present cases, there have been 27 cases of bronchial atresia reported in Japan. The Japanese literature was reviewed and discussed.

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A 63 year-old man with silicosis and old lung tuberculosis was admitted complaining of cough and hemosputum. At bronchoscopy a smooth surfaced polypoid tumor was found projecting into the right main bronchus. As biopsy of the tumor showed nonspecific inflammatory granulation tissue, endobronchial resection of the tumor using an electrosurgical snare was performed through the flexible fiberoptic bronchoscope. The tumor was resected satisfactorily, and histopathological and bacteriological studies confirmed the diagnosis of nonspecific inflammatory polyp of the bronchus. Inflammatory polyp of the bronchus is a very rare benign endobronchial tumor, and endoscopic electrosurgical resection of the polyp can be a very useful procedure.

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Intraalveolar organization was detected in 83 (5.7%) of 1454 cases in which TBLB was performed in our institute. Intraalveolar organization was recognized in the TBLB specimens from cases of not only pneumonia but also interstitial pneumonia, pulmonary tuberculosis, lung cancer, hypersensitivity pneumonia and so on, so it was not related to any specific pathological condition. We studied 20 cases of pneumonia showing intraalveolar organization. In most cases, they had underlying diseases including 4 malignant tumors, 4 old tuberculosis, 2 diabetes mellitus and 4 others. We performed TBLB in 15 cases whose chest X ray did not improve in spite of receiving antibiotics, and in 5 cases not receiving therapy. In all cases who had received antibiotics, we performed TBLB within 2 months from commencement of medication. We changed antibiotics in half of the 20 cases of pneumonia, after intraalveolar organization was found. Abnormal chest X ray shadows disappeared in half of the 20 cases, but micronodular or cord-like shadow remained in some cases. In conclusion, the majority of cases of pneumonia showing intraalveolar organization in the TBLB specimens, had underlying diseases, and abnormal chest shadows disappeared within 3 months in half of them suggesting that such cases do not always have very slow course.

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Tracheal leiomyoma is a rare disease and only 19 cases have been reported in the world literatures. The authors report this case and also discuss the literatures. The patient was a 78-year-old woman and her complaints were cough, fever and dyspnea. The examinations revealed intratracheal tumor which located 8cm oral to the carina. After mid-sternal incision was made, tumor was removed including two tracheal cartilages and end-to-end anastomosis of the trachea was performed. The histologic examination revealed leiomyoma and the patient is now doing well without any signs of recurrence one year after the operation.

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Leiomyoma of the trachea and bronchus is a rare tumor, only 31 cases having been reported in the Japanese literature. We report here a case of leiomyoma of the right upper lobe bronchus which was successfully operated on. A 66 year-old man visited our hospital because of hemosputum. The diagnosis of leiomyoma of the bronchus was made by a preoperative bronchofiberscopic biopsy. Thoracotomy was made by right posterolateral incision at the Vth rib bed. End to end anastomosis was performed after sleeve resection of the right upper lobe bronchus containing the tumor. The removed specimen revealed that a tumor with smooth surface protruded into the bronchial lumen. It was elastic, hard and 5×4×4 mm in size. Microscopic examinations showed that the tumor originated from bronchial smooth muscle, covered with striated columner epithelium, and was composed of intertwining bundle of spindle cells. The final pathological diagnosis was that of leiomyoma with no evidence of malignancy. Thirty-two cases containing the present case were clinically reviewed.

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A 65 year-old male was diagnosed as small cell carcinoma of the lung (intermediate type T_2N_oM_o). He was treated with chemotherapy and the tumor disappeared. Two years later he was admitted because of dyspnea. Tomography showed an endotracheal tumor below the vocal cord. Tracheostomy was performed as an emergency procedure. Histological examination of the biopsied specimen revealed small cell carcinoma (intermediate type). He was treated with irradiation and the tumor disappeared. This endotracheal tumor was thought to be a metastic lesion from lung cancer, because no membranous changes of other parts of the trachea and bronchial wall were seen and no other organ had metastasis.

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Case 1 is occult lung cancer of 59-year-old man. Histological examination of surgical specimen shows double primary squamous cell lung cancers, one is microinvasive carcinoma at the orifice of right B^<8+9+10> with little bronchoscopic findings, and the other is in situ carcinoma with no bronchoscopic findings. Case 2 is triple primary squamous cell lung cancers of 75-year-old man. The first is at the orifice of left upper lobe bronchus, the second is at the orifice of right upper lobe bronchus, the third is at the orifice of the spur between right B^7 and B^<8+9+10>. The first and the second are nodular infiltrating type squamous cell carcinomas, but the third of right lower lobe is minute lesion without roentgenological and bronchoscopical findings. We should consider the possibility of overlooking minute cancer at routine bronchoscopic examination.

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Thymomas are frequently found by abnormal findings on chest X ray film because most patients with thymomas have no symptom. Some cases have thoracodynia or dyspnea, but hemoptysis due to thymoma invading the bronchus has not yet been recorded in the medical literature. A 56 year-old woman complained of hemoptysis. Her chest X ray film showed an abnormal tumor shadow in the left superior mediastinum and lung field. We found an intraluminal polyp in the bronchus of the anterior segment of the left lung by bronchofiberscopy and diagnosed the tumor as a lung cancer. Histopathological examination with immunological staining method (Leu 7) of the biopsy specimen of the polyp revealed that the tumor was invasive thymoma. The upper lobe of the left lung with the tumor was successfully resected and examination of the surgical specimen showed that the mediastinal tumor invaded the lung and expanded into the left bronchus. This is the first reported case of invasive thymoma causing hemoptysis and exhibitting an unusual growth pattern in the bronchus.

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