Lung transplantation and lung volume reduction surgery (LVRS) are considered as treatment options for eligible patients with severe chronic obstructive pulmonary disease (COPD). However, lung transplantation for COPD is constrained by patient age restrictions and donor shortage, while the number of LVRS procedures performed in Japan remains limited because of the high surgical invasiveness and the high rate of postoperative complications. Bronchoscopic lung volume reduction (BLVR) is a less-invasive alternative for reducing the lung volume without needing thoracotomy. BLVR utilizes bronchial valves and involves placing a one-way valve in the bronchus of a hyperinflated emphysematous lobe, consequently reducing the lung volume. These valves block inhalation while permitting exhalation from the peripheral lung bronchus.

In 2018, this treatment method received approval from the U.S. Food and Drug Administration for the treatment of severe emphysema and was covered by health insurance from Japan since December 1, 2023. The success of one-way valve BLVR depends on the careful selection of severe emphysema and hyperinflation patients, who do not have collateral ventilation to the target lobe, and on achieving a complete occlusion of the target bronchus with the valve. Postoperative management is crucial, particularly in preventing complications like pneumothorax. In Japan, BLVR was initially implemented in selected high-volume centers with specialized expertise. The first 140 cases are undergoing post-marketing surveillance to evaluate efficacy and safety. This article provides a review of one-way valve BLVR.

Background: Central airway obstruction caused by benign or malignant diseases can be life-threatening. Selecting the optimal therapeutic bronchoscopy technique is critical, particularly when re-intervention is required. This study reviews various bronchoscopy modalities for initial and re-intervention procedures in patients with central airway disorders.

Materials and Methods: A retrospective review was conducted on patients with central airway disorders who underwent therapeutic bronchoscopy between May 2005 and January 2018 at a single institution.

Results: A total of 359 therapeutic bronchoscopy procedures (119 benign and 240 malignant cases) were performed in 234 patients; of these, 337 airway stents were placed in 235 procedures. Silicone stents were used in 31 (38.8%) benign and 28 (10.9%) malignant cases. Additionally, 108 non-stenting procedures and 16 stent removal procedures were performed. First interventions comprised 205 procedures (57.1%), while 154 procedures (42.9%) were re-interventions. Re-intervention was performed in 79 (66.4%) benign and 75 (31.3%) malignant cases, indicating that it was significantly more common in benign cases (p < 0.0001). In benign cases, re-interventions were primarily due to granulation tissue formation after stenting (n = 29) and recurrence of scar stricture (n = 23). In malignant cases, tumor regrowth (n = 42) and granulation tissue formation after stenting (n = 17) were the main causes.

Conclusions: Various interventional procedures were applied to patients with central airway disorders. Repeated therapeutic bronchoscopy is often required because of disease progression or procedure-related complications. Benign diseases had a higher re-intervention rate, highlighting the importance of long-term management and follow-up.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare and frequently fatal complication associated with advanced gastric cancer, characterized by progressive dyspnea, pulmonary hypertension, and right heart failure. Diagnosing PTTM is challenging owing to its rapid progression and ability to mimic other respiratory conditions. Transbronchial lung cryobiopsy (TBLC) has recently emerged as a valuable diagnostic tool, providing larger and more intact tissue samples than conventional transbronchial lung biopsy (TBLB), which is often limited by tissue crush artifacts.

We present a case of a 58-year-old male with rapidly worsening dyspnea, hypoxemia, and right heart strain. Chest computed tomography revealed interlobular septal thickening and ground-glass opacity. TBLC from the right lower lobe confirmed a diagnosis of PTTM, with tumor cells detected in the pulmonary vessels and fibrous intimal thickening. Upper gastrointestinal endoscopy revealed Borrmann type 4 gastric cancer. Despite planning chemotherapy, the patient succumbed to cardiopulmonary arrest.

This case highlights the importance of TBLC as a diagnostic method for PTTM, as it can facilitate earlier detection and treatment. Further study is required to evaluate the safety of TBLC and explore potential therapeutic strategies for improving patient outcomes in PTTM.

In this study, a 60-year-old man with psoriatic arthritis receiving adalimumab was referred for abnormalities found from the results of his chest radiograph and computed tomography (CT) scan. He did not have a fever, and the blood tests showed no remarkable findings. Nonenhanced CT revealed mediastinal lymphadenopathy. We performed a bronchoscopy, specifically endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), of the subcarinal lymph node (#7). The tissue cultures obtained by EBUS-TBNA were positive for Mycobacterium tuberculosis (M.Tb). The tissue M.Tb polymerase chain reaction (TB-PCR) test was also positive, but the culture and the TB-PCR of the bronchial wash fluid and rinse fluids of the brush and the needle of EBUS-TBNA were negative for M.Tb. A mediastinal tuberculous lymphadenitis (TBL) diagnosis was made, and the patient was prescribed antituberculosis drugs for 9 months. After the completion of the antituberculosis treatment, the size of the mediastinal lymph nodes reduced. In conclusion, performing EBUS-TBNA and analyzing the culture and the TB-PCR of the tissue obtained by EBUS-TBNA to test for susceptibility to M.Tb may aid with TBL diagnosis and treatment.

This study describes a unique case of visceral pleural perforation during ultrathin bronchoscopy in a 65-year-old man with a history of asbestos exposure, who presented with a subpleural tumor in the right middle lobe. An ultrathin bronchoscope with a 3.0 mm outer diameter was used to obtain a biopsy specimen. During the procedure, the bronchoscope inadvertently caused a visceral pleura perforation, which led to mild pneumothorax, as confirmed by post-procedure computed tomography imaging. Although the pneumothorax did not require chest drainage, the potential risk of pleural tumor seeding prompted a wedge resection after 2 days. A histopathological examination revealed tumor invasion beyond the external elastic lamina, with pleural surface exposure. The tumor was subsequently diagnosed as Anaplastic lymphoma kinase (ALK) fusion gene-positive lung adenocarcinoma. The patient opted for treatment with an ALK inhibitor rather than further lymph node dissection. This case emphasizes the importance of careful handling of ultrathin bronchoscopes during procedures near the pleura because their increased precision and ability to reach peripheral airways can lead to rare but significant complications, such as pleural perforation.

Primary lung cancer can rupture into the pleural cavity, leading to pleural empyema with bronchopleural fistula (BPF). Although early surgery is recommended for this condition, it can be challenging in patients for whom surgery is inappropriate. A 75-year-old man diagnosed with stage IVB non-small cell lung cancer was administered carboplatin and nab-paclitaxel. On day 11, the patient visited our hospital with a high fever. Chest radiography and computed tomography revealed a large left hydropneumothorax. Since hydropneumothorax occurred rapidly after chemotherapy, tumor rupture was considered. The fever subsided after antibiotic treatment and thoracic drainage; however, there were air leakage from the drainage tube and continuous discharge of pus from the BPF. Subsequently, bronchial occlusion using an endobronchial Watanabe spigot (EWS) was performed to arrest pus drainage from the bronchi. The tip of the EWS was grasped using forceps through a bronchoscope, and the plug was inserted into B¹⁺²c; the air leakage subsequently diminished. He was discharged on day 48, and there was no recurrence of pleural empyema after discharge. Pleural empyema with a BPF can occur secondary to tumor rupture into the pleural cavity, and bronchial occlusion using an EWS may be a treatment option.

A man in his seventies who was being treated for bacterial pneumonia showed no signs of improvement. Thus, bronchoscopy was performed to investigate the cause of pneumonia. Midazolam and fentanyl infusions and localized lidocaine were administered, and the patient developed cough. After two infusions of 50 mL of normal saline into the right lower lobe bronchus, the right lung lobe was observed, and the bronchoscope was taught to exit the bronchus. Chest radiography and chest computed tomography revealed a right pneumothorax. The pneumothorax resolved with oxygen therapy, and the patient recovered from pneumonia. Although pneumothorax is a rare complication of bronchoalveolar lavage, we halted the procedure and conducted sedation assessment when the patient experienced a severe cough.

We describe a patient without symptoms and with multiple lung nodules, which was diagnosed as actinomycosis by bronchoscopy. Pulmonary actinomycosis shows a variety of features in chest images. However, multiple nodular lesions are very rare. We believe the infection was spread through the airway by oral infection. An anaerobic culture obtained from the bronchial washing fluid was useful.

A 61-year-old woman was referred to our hospital after a chest computed tomography scan revealed a mass lesion in the right lower lobe. The mass had been growing for 4 years, with a branching shadow at its periphery showing a finger-in-glove sign. A forceps biopsy was performed using a bronchoscope, which was suspicious for papilloma; however, malignancy could not be ruled out. Thoracoscopic surgery was subsequently performed, confirming the diagnosis of sialadenoma papilliferum (SP). SP is a rare benign tumor of the salivary glands, with recent reports focusing on its pathological and immunological characteristics. Although SP can also occur in the bronchi, reports on pulmonary SP are limited, and many of its characteristics remain unknown. This case provides clinically useful information for managing pulmonary SP.

Introduction: Incomplete resection of mediastinal bronchogenic cysts can lead to recurrence. However, bronchogenic cysts often occur in the middle mediastinum and are surrounded by vital organs, making complete resection problematic.

Technical Report: We report our experience with intraoperative sclerotherapy using absolute ethanol in cases of mediastinal bronchogenic cysts in which complete resection was considered problematic. The methods used were as follows: (1) use of a double-balloon catheter to prevent ethanol leakage and (2) intraoperative fluoroscopy to confirm no communication with adjacent organs and no ethanol leakage during sclerotherapy.

Conclusions: The method used was safe because it prevented absolute ethanol leakage from the cyst, which could damage surrounding tissue. Even in cases in which the tumor was incompletely resected, no recurrence occurred over a long period. Thus, the proposed method is considered useful.