Hemoptysis is a symptom with a high mortality rate. The in-hospital mortality rate of hospitalized patients with hemoptysis is 5%-9%. Bronchial artery embolization was formerly positioned as an emergency treatment for massive hemoptysis. Nowadays, it has become a standard treatment for elective treatment for chronic recurrent hemoptysis. Despite the high mortality rate, only 2%-8% of hospitalized patients with hemoptysis underwent Bronchial Artery Embolization (BAE). One possible reason is the concern about spinal cord infarction, followed by the shortage of operators specializing in BAE.

The incidence rate of spinal cord infarction was 0.18%, 0.71%, and 0.06% for gelatin sponge, n-butyl-2-cyanoacrylate (NBCA), and coil, respectively, in a nationwide observational study in JAPAN. CIRSE (Cardiovascular and Interventional Radiological Society of Europe) guideline states that BAE by the coil is relatively safe and spinal-protective based on this study.

BAE is primarily performed by radiologists and is a unique intervention targeting various arteries throughout the thorax, often smaller than 2 mm and, in some cases, less than 1 mm. The authors believe that it is essential to increase the number of pulmonologists subspecializing in BAE, like cardiologists and neurosurgeons who perform catheter treatment in their field.

This paper aims to provide a technical and practical Expert Review of BAE by coil for pulmonologists based on our experience at a high-volume center managed by pulmonologists. The authors will also discuss a general narrative review on classifications of hemoptysis and BAE because we are concerned about the extreme international inconsistency in classifying and defining hemoptysis-related matters and will propose some challenging suggestions depending on our experience to rectify this situation.

Interventional pulmonology for central airway obstruction caused by malignancy is a purely and the only palliative therapy that is only carried out for patients who are ineligible for surgery. Interventional options for central airway obstruction are subject to the availability of experienced personnel and equipment. This study reviews the procedure for interventional pulmonology using rigid bronchoscopy to treat central airway obstruction, stent placement, and post-stent-placement complications.

Background: Studies on airway-stent removal, a dangerous procedure that involves a difficult decision-making, are scarce. We aimed to use our experience with trials of removal on airway stenosis to elucidate predictors of a successful airway-stent removal.

Materials and Methods: We retrospectively analyzed clinical data of 11 patients with central airway stenosis or obstruction who underwent trial of airway-stent removal at Toho University Omori Medical Center between 2002 and 2021.

Results: A total of nine patients had benign airway stenosis, of whom four and five had successful and failed removal, respectively. Two patients had stenosis caused by a malignant disease, and both underwent successful removal. All patients with postoperative stenosis had failed removal, although no significant difference was observed between patients with successful and failed removal. Tracheal and bronchial rings at the stenotic portion had a significant difference between patients with successful and failed removal. All patients with tracheal and bronchial rings had successful removal, although one patient without tracheal and bronchial rings had successful removal. All patients that lacked space around the stent, stent migration, and tracheal and bronchial rings had failed removal attempts. A significant difference was observed in the presence of these factors between patients with successful and failed removal.

Conclusions: Patients with malignant airway stenosis may undergo successful removal of airway stents, whereas patients with benign airway stenosis may not always have successful removal. In patients with airway stenosis, space around the stent, stent migration, and tracheal and bronchial rings may be predictors of successful airway-stent removal.

Background: Approximately 5%-15% of surgically treated cN0 non-small cell lung cancers (NSCLCs) are classified as pN2 disease (cN0/pN2). Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a widely accepted minimally invasive nodal staging modality with a high diagnostic yield. We compared the survival outcome of cN0/pN2 patients who underwent preoperative EBUS-TBNA with that of patients who underwent radiological examinations alone.

Materials and Methods: A retrospective chart review was conducted to assess the prognosis of patients with cN0/pN2 NSCLC who underwent radical surgery with curative intent. EBUS-TBNA was indicated when cN1-2 disease was suspected based on the radiological findings.

Results: Among the 812 cN0 patients, 56 (6.9%; 36 men and 20 women; average age: 65.9 years) were diagnosed with pN2 disease postoperatively. A total of 17 (30%) patients were diagnosed with cN0 using EBUS-TBNA (Group A) and 39 (70%) with cN0 using radiological examinations alone (CT and PET) (Group B). No significant differences were observed between the clinical and pathological backgrounds of the two groups. The 5-year overall and recurrence-free survival rates were 57.6% and 27.4% in Group A and 51.1% and 21.9% in Group B, respectively. No significant difference in survival was observed between the two groups.

Conclusions: Patients with unsuspected pN2 demonstrated similar overall survival to those in previous reports, regardless of the difference in preoperative nodal staging modality.

Background: Optimal management of lung cancer requires an accurate diagnosis and a safe and comfortable examination method allowing acceptable rebiopsy. Endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is associated with lesser pain than endoscopic ultrasound-guided fine-needle aspiration but has the same diagnostic ability for mediastinal lesions as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Thus, it has become increasingly popular among respiratory endoscopists. However, studies on the utility and diagnostic yield of EUS-B-FNA for neoplastic lesions inside and outside the lung adjacent to the esophagus are limited. Thus, this study aimed to investigate the utility of EUS-B-FNA for diagnosing neoplastic lesions inside and outside the lung adjacent to the esophagus.

Materials and Methods: We retrospectively reviewed 47 consecutive patients who underwent EBUS-TBNA or EUS-B-FNA for neoplastic lesions inside and outside the lung adjacent to the esophagus at Hakodate Goryoukaku Hospital between July 2019 and November 2021. The following factors were analyzed: diagnostic rates; cumulative doses of lidocaine, midazolam, and fentanyl; patient satisfaction evaluated with a questionnaire survey; and procedural complications.

Results: The diagnostic rates with EBUS-TBNA and EUS-B-FNA were 70.0% (14/20) and 96.3% (26/27), respectively. The median dose of midazolam (16.5 mg vs. 14 mg; P = 0.017) and lidocaine (240 mg vs. 32 mg; P < 0.001) was significantly low with EUS-B-FNA. The mean level of discomfort during bronchoscopy was significantly low in EUS-B-FNA (2.25 vs. 1.56; P = 0.025).

Conclusions: Although EUS-B-FNA differs from EBUS-TBNA in some diagnostic areas, EUS-B-FNA for neoplastic lesions inside and outside the lung adjacent to the esophagus has a higher diagnostic rate and examination comfort. Mastering EUS-B-FNA may improve the diagnostic capabilities of respiratory endoscopists.

Lymphangitis carcinomatosa is a type of pulmonary metastasis with a poor prognosis. Transbronchial lung biopsy and bronchoalveolar lavage (BAL) are used for its histologic diagnosis, but improved diagnostic yield is needed. Transbronchial lung cryobiopsy (TBLC) is useful in diagnosing interstitial lung diseases and might be useful in diagnosing lymphatic invasion of tumor cells. A 60-year-old man presented with low-grade fever and dyspnea 1 year after a right lower lobectomy. Chest computed tomography showed generalized ground-glass opacities in his lungs. Bronchoscopy was performed for a definitive diagnosis of ground-glass opacites following ineffective antimicrobial therapy. BAL showed no malignant cells, and TBLC showed tumor cells infiltrating the lymphatic vessels. Multiplex polymerase chain reaction testing was available for the TBLC specimen, and treatment based on genetic test results was introduced. In conclusion, TBLC enabled a clear diagnosis of lymphatic invasion of tumor cells and enabled multiplex examinations. TBLC is a useful tool for respiratory endoscopists in diagnosing lymphangitis carcinomatosa.

We herein report a case of a bronchobiliary fistula that was successfully treated for bronchial occlusion using an Endobronchial Watanabe Spigot (EWS) and embolization coils. A 66-year-old man who underwent radiofrequency ablation for hepatocellular carcinoma and endoscopic retrograde cholangiopancreatography for acute cholangitis developed a bronchobiliary fistula. Surgical treatment was difficult due to the patient's medical history and the underlying disease progression. Although percutaneous bile drainage was performed, only a partial response was observed. Thus, bronchial occlusion was treated using EWS and embolization coils. This case suggests that bronchial occlusion using bronchoscopy is a safe and effective treatment option for bronchobiliary fistulas.

We describe a case of aspiration pneumonitis with 10% (w/v) benzalkonium chloride (BAC) that proved disinfectant in bronchi using an anionic surfactant.

After gargling with 10% (w/v) BAC, a 72-year-old woman experienced pharyngeal irritation, developed a strong cough, and was transferred to the emergency room. The aspirated fluids were removed with a bronchoscope. Since test reagents were unavailable to prove that the bronchial fluid contained BAC (a cationic surfactant), we used an anionic surfactant (liquid soap) that could be considered to form micelles when mixed with BAC. Results showed that the fluid contained BAC because it rapidly became cloudy when mixed with liquid soap. Her symptoms improved after only seven days of administering systemic methylprednisolone and ampicillin/sulbactam.

Early diagnosis and treatment of chemical aspiration pneumonitis are crucial. Physicians should pay close attention when diagnosing respiratory symptoms after gargling, especially during the COVID-19 pandemic.

The case involves a 57-year-old man with a history of laryngeal and lung cancers. He underwent a laryngectomy and right upper lobectomy and developed tracheal methicillin-resistant Staphylococcus aureus (MRSA) colonization. He also underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to diagnose right mediastinal lymph node adenopathy. His recovery was complicated by a mediastinal infection caused by MRSA five days post-procedure. Combining triple antibiotics comprising MEPM, DAP, and VCM for three weeks gradually improved the mediastinal infection. To our knowledge, this is the first report of mediastinal infection caused by MRSA after EBUS-TBNA. Our successful treatment of EBUS-TBNA-related infectious complications gives us information regarding rare complications management caused by EBUS-TBNA.

The prognosis for mixed connective tissue disease (MCTD) cases complicated with pulmonary hypertension (PH) remains poor. We report a case of MCTD complicated with PH in which respiratory failure was exacerbated by pregnancy and delivery. She experienced Raynaud phenomenon and exacerbating dyspnea on exertion, coughing, and oxygen desaturation in her pregnancy and the postpartum period and was admitted on the fifth day after delivery. Serological tests revealed a high titer of anti-U1 ribonucleoprotein (RNP) antibody. Chest computed tomography scan showed the nonspecific interstitial pneumonia (NSIP) pattern, and the right heart catheterization showed high mean pulmonary artery pressure. She was diagnosed with MCTD complicated with PH. Transbronchial lung cryobiopsy revealed a pathological finding suggestive of early plexiform lesions, indicating the cause of PH to be pulmonary arterial hypertension rather than the interstitial change in the lung. She was successfully treated with the combination therapy of immunosuppressants and a pulmonary vasodilator. When transbronchial cryobiopsy is performed in cases of interstitial pneumonia complicated with PH, pathological evaluation of pulmonary arterioles can be a good option because pulmonary vasodilators should be administered with great caution to other than pulmonary arterial hypertension.

IgG4-related diseases present with various pulmonary lesions, and respiratory dysfunction follows the pattern of pulmonary lesions. Few cases of severe obstructive ventilatory defect have been reported. We experienced a case of IgG4-related respiratory disease with severe obstructive ventilatory defect due to marked thickening of the lower respiratory tract. An 82-year-old woman presented with sputum, cough, and dyspnea on exertion for 4 years. She was considered to have severe chronic obstructive pulmonary disease and was prescribed tiotropium, but her symptoms progressed. Serum IgG4 was elevated, and the chest computed tomography (CT) showed that the bronchial walls thickened with a central predominance and the lobe bronchi were obstructed. Bronchoscopy revealed marked thickening of the trachea and bilateral main bronchi, some of which had pinhole stenosis. Pathological examination of the bronchial wall showed infiltration of IgG4-positive cells, meeting the diagnostic criteria for IgG4-related disease. Treatment with systemic corticosteroid normalized pulmonary function and improved CT findings, and a small maintenance dose of steroids provided long-term stabilization for 11 years. IgG4-related respiratory disease can be a differential disease for obstructive ventilatory defect and have an excellent long-term prognosis. Lower airway thickening on chest CT and high serum IgG4 levels facilitated the diagnosis.

Alveolar hemorrhage may occur during an acute exacerbation of interstitial lung disease (AE-ILD) or may be caused by a negative pressure mechanism due to upper airway obstruction such as laryngospasm in the perioperative period. There have been no reports of negative pressure pulmonary hemorrhage (NPPH) due to laryngospasm without obvious invasive factors. We experienced a case of repeated NPPH due to idiopathic laryngospasm, resembling an AE-ILD. A 62-year-old woman developed multiple alveolar hemorrhages due to a sense of obstruction in the throat, followed by bloody sputum and dyspnea. She was considered to have an AE-ILD with Sjögren's syndrome and was treated with immunosuppressive therapy but had recurrent relapses. Bronchoscopy was performed under minimal anesthesia to elicit the cough reflex by vocal cord stimulation, and findings of internal rotation and complete occlusion of the vocal cords were confirmed. She was diagnosed as NPPH due to laryngospasm, and she has been treated with muscle relaxants without recurrence. NPPH due to laryngospasm can be a differential diagnosis as a cause of alveolar hemorrhage. By confirming the diagnosis through bronchoscopic examination of the larynx under minimal anesthesia, unnecessary immunosuppressive treatment for suspected AE-ILD can be avoided and appropriate preventive treatment can be provided.

Acute fibrinous and organizing pneumonia (AFOP) is a rare interstitial lung disease histologically characterized by massive intra-alveolar fibrin deposition without a hyaline membrane and eosinophilic infiltration. We report a case of idiopathic AFOP with golden-yellow bronchoalveolar lavage (BAL) fluid. The histological examination of the transbronchial lung biopsy specimen demonstrated massive fibrinous exudates in most of the alveolar spaces. The golden-yellow BAL fluid was thought to be due to the intense exudation of the plasma components into the alveoli. The cellular fractionation of the BAL fluid showed 47% neutrophils, 36% lymphocytes, 11% macrophages, and 5% eosinophils, combining features of diffuse alveolar damage (DAD) and cryptogenic organizing pneumonia (COP). The patient showed rapid clinical improvement with prednisolone therapy, although the AFOP relapsed during the tapering of prednisolone, and required cyclosporine in addition to prednisolone. AFOP is considered a condition between DAD and COP and might not follow a single disease concept. Golden-yellow BAL fluid might be useful for differentiating AFOP from COP.

Among various types of aspergillosis, the clinical features of patients with obstructive bronchial aspergillosis remain unclear. Originally, it was reported to occur only in severely immunocompromised patients, such as acquired immunodeficiency syndrome (AIDS) or post-organ transplantation; however, recent reports have suggested that this disease could also affect patients seen in daily practice of pulmonary medicine. We describe a case of a 76-year-old woman with obstructing bronchial aspergillosis. This patient presented to the hospital with a productive cough during asthma and advanced lung cancer treatment. Chest CT showed stenosis of the bronchial lumen. Bronchoscopy showed no recurrence of lung cancer, and aspergillus was found in the granulation tissue. The cough improved with debridement of the lesion by bronchoscopy and oral antifungal medication treatment. Our review of previous case reports, including this case, revealed that obstructing bronchial aspergillosis might occur when patients have several factors inducing immunosuppression, such as solid tumors under anticancer treatment, inhaled corticosteroids, and aging. Since patients may be at risk of progressing to invasive aspergillosis, physicians must properly diagnose obstructing bronchial aspergillosis to deliver appropriate treatment.

Pulmonary malignancies coexisting with opportunistic infections can often be challenging to diagnose. In this study, we present an unusual case of methotrexate-associated lymphoproliferative disease (MTX-LPD) coexisting with Aspergillus infection, during treatment of psoriatic arthritis, which presented as multiple systemic mass shadows, including pulmonary mass shadows. Though suspected of being lung cancer initially, bronchoscopy revealed the presence of only Aspergillus; subsequent computed tomography-guided adrenal and direct skin biopsies have confirmed the diagnosis of LPD associated with MTX. Although coexistence of Aspergillus infection in lymphoma is considered unusual, clinicians need to be vigilant about opportunistic infections in patients taking MTX or those who are immunocompromised; thus, these pathogens should be considered when determining differential diagnosis. Furthermore, rather than performing bronchoscopy multiple times, there are a number of examinations that can make the diagnostic process more efficient, as in this case.

Bronchogenic cysts are cystic lesions derived from an abnormal lung bud originating from the foregut and are often discovered incidentally on imaging. We report a case of a bronchogenic cyst presenting with hoarseness, a rare symptom. A 44-year-old man with a history of hypertension and hyperuricemia presented to our hospital with a chief complaint of hoarseness. The chest x-ray showed an enlarged mediastinal shadow. Chest computed tomography (CT) revealed a tumor measuring 9 cm in diameter in the middle mediastinum, under the aortic arch. Contrast-enhanced CT revealed an internally homogeneous tumor with contrasted margins. Since a symptomatic bronchogenic cyst was suspected, we performed surgery. Intraoperative findings showed the tumor was large and strongly adherent to adjacent structures. Therefore, we performed a partial resection of the tumor wall, preserving the vagus and recurrent nerves, but could not perform a complete resection. Histopathological examination confirmed the diagnosis of a bronchogenic cyst. The patient showed an uneventful postoperative course, and his hoarseness gradually improved and disappeared approximately 3 months after the surgery. We report a case of mediastinal bronchogenic cyst presenting with hoarseness. Hoarseness was induced by a bronchogenic cyst, and tumor resection improved the symptoms.

Invasive mucinous adenocarcinoma (IMA) is a subtype of lung adenocarcinoma with a poor prognosis. Delays in diagnosis and treatment are problematic due to the nonspecific symptoms of cough and sputum and the difficulty of diagnosis by bronchoscopy forceps biopsy. Transbronchial cryobiopsy (TBCB) is a lung biopsy technique that endoscopically obtains large specimens with limited crush artifacts. A 61-year-old woman presented to our hospital with a productive cough. Chest computed tomography (CT) showed mixed ground-glass opacities and consolidation of the right lower lobe. A forceps biopsy was performed endoscopically on the right lower lobe. However, no malignant findings were observed on histological examination. Therefore, we suspected organizing pneumonia and treated the patient with steroids as a diagnostic treatment. However, she did not improve. Her productive cough worsened during steroid tapering, and CT showed increased consolidation. We concluded that rebiopsy and TBCB were needed. Histopathologic examination revealed alveolar replacement of tumor cells with mucus, confirming the diagnosis of IMA. IMA, which is difficult to diagnose using forceps biopsy, can be diagnosed using TBCB. Clinicians might want to consider using TBCB for biopsies of persistent alveolar shadows similar to those of IMA.

An 82-year-old woman with severe bilateral sensorineural hearing loss visited our hematology department for the management of essential thrombocythemia. Approximately 5 months before her presentation, she developed dyspnea on exertion and underwent cardiac catheterization for suspected heart failure; however, no cause was identified. Approximately 4 months later, she was referred to the respiratory department with a persistent cough. Bronchial asthma was suspected, and pulmonary function tests were performed. In the meantime, inhaled steroid therapy was prescribed. Two days later, her dyspnea worsened, and she was rushed to our hospital, where she was found to have wheezing and hypoxemia. However, her cardiac function was preserved. Contrast-enhanced computed tomography of the chest revealed a mass protruding into the trachea, resulting in intratracheal stenosis. Two biopsies were obtained from this area in two separate bronchoscopies while the patient was intubated to secure her airway. Pathological examination of the biopsies revealed only inflammatory granulation tissue. Steroid medication was continued to prevent laryngeal edema, and the elevated intratracheal lesion resolved. Given the presence of bilateral sensorineural hearing loss probably caused by cochlear dysfunction, suspected respiratory chondritis, and favorable response to corticosteroid administration, our final diagnosis was relapsing polychondritis.