Assessment of Extensive Airway Obstruction Using Point-by-Point Lateral Pressure Measurements during Bronchoscopy.

BACKGROUND: The positioning of the stent at the flow-limiting segment is crucial for patients with extensive airway obstruction to relieve dyspnea. However, CT and flow-volume curves cannot detect the area of maximal obstruction. OBJECTIVES: The aim of this study is to physiologically evaluate extensive airway obstruction during interventional bronchoscopy. METHODS: We prospectively measured point-by-point lateral airway pressure (Plat) at multiple points from the lower lobe bronchus to the upper trachea using a double-lumen catheter in 5 patients. The site of maximal obstruction was evaluated continuously to measure point-by-point Plat at multiple points when the airway catheter was withdrawn from the lower lobe bronchus to the upper trachea. RESULTS: Remarkable pressure differences occurred at the site of maximal obstruction assessed by point-by-point Plat measurements. After initial stenting in 1 case, migration of the maximal obstruction to a nonstented segment of the weakened airway was seen with extensive stenosis from the trachea to the bronchi. In the second case, in addition to radiological analysis, point-by-point Plat measurements could identify the location of the maximal obstruction which contributed to dyspnea. CONCLUSIONS: Point-by-point Plat measurement could be used to detect the site of maximal obstruction physiologically. Furthermore, Plat measurement could assess the need for additional procedures in real time in patients with extensive airway obstruction.

Comparison of the 22-gauge and 25-gauge needles for endobronchial ultrasound-guided transbronchial needle aspiration.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive hilar mediastinal node sampling technique used for lung cancer staging and diagnosis of lesions. Besides the conventional 22-gauge (G) and 21G needles, a 25G needle is now available for this procedure. The objective of this study was to evaluate the efficacy of the 25G EBUS-TBNA needle. METHODS: We retrospectively reviewed consecutive patients who underwent EBUS-TBNA using both 22G and 25G aspiration needles from January 2017 through December 2017 at St. Marianna University School of Medicine. We identified 10 patients and compared the diagnostic yield and the sample volume for each needle. RESULTS: Six patients were diagnosed with lung cancer and four with sarcoidosis. Total diagnostic yield was 80% (8/10) for the 22G and 60% (6/10) for the 25G (P = 0.31). In patients with lung cancer, the diagnostic yield was 67% (4/6) for the 22G and 83% (5/6) for the 25G (P = 0.50). In patients with sarcoidosis, the diagnostic yield was 100% (4/4) for the 22G and 25% (1/4) for the 25G (P = 0.07). In patients with lung cancer, the median tissue area was comparable for each needle; however, in patients with sarcoidosis, the sample area was smaller for the 25G than for the 22G. We did not encounter any major complications or bleeding during EBUS-TBNA procedures. CONCLUSIONS: Although histologic specimens obtained by the 25G needle are expected to be useful for the diagnosis of lung cancer, we found the 25G needle inadequate for diagnosing sarcoidosis due to insufficient sample size.

Drastic healing process after pembrolizumab monotherapy in a case of advanced squamous cell carcinoma with severe bronchial stenosis observed over a two-year period using continuous bronchoscopy: A case report.

Programmed cell death-1 immune checkpoint inhibitor (ICI) antibody has proven to be effective in advanced non-small cell lung cancer (NSCLC) patients positive for programmed cell death-1 ligand-1. However, there are currently no reports which evaluate drug efficacy by continuous bronchoscopic observation. A 75-year-old man with complete right atelectasis was diagnosed with squamous cell carcinoma (SCC) of the right lower lobe (tumor proportion score: TPS 90%, cT4N3M0, stage 3C). For first-line chemotherapy, carboplatin and nab-paclitaxel were effective for the primary lesion and the right lung atelectasis improved. However, due to repeated febrile neutropenia with pneumonia, treatment was modified to pembrolizumab monotherapy. Bronchoscopic rebiopsy prior to second-line treatment revealed high TPS, with a severe stenosis in the right main bronchus. After three courses of pembrolizumab, the right main bronchus opened completely, and no signs of malignancy were observed. Bronchoscopic narrow-band and autofluorescence imaging also confirmed a complete endobronchial response. Subsequent bronchoscopic observation two years after the initial diagnosis showed a complete and continued response to treatment. ICIs can result in a drastic bronchoscopic response. In this case, the healing process was notable with minimal scarring, and resulted in continued locally bronchoscopic and complete pathological response to treatment compared to previous cytotoxic chemotherapy.

Complicating effects of obstructive sleep apnea syndrome on the severity of adult asthma.

Introduction: Bronchial asthma (BA) and obstructive sleep apnea syndrome (OSAS) are common causes of respiratory disturbance. Many cases of patients with both conditions have been reported, and BA and OSAS may exacerbate each other, but information remains sparse.Methods:We retrospectively evaluated 60 patients under treatment for BA in our department between April 2016 and March 2018 who also underwent portable polysomnography (PSG) for suspected OSAS to assess potential association between PSG results and asthma treatment or respiratory function. BA was diagnosed and treated according to the Asthma Prevention and Management Guideline 2015.Results: We found that BA treatment intensity step was significantly higher for patients with BA who had concurrent moderate or severe OSAS (p = 0.0016). However, neither respiratory function, fraction of exhaled nitric oxide (FeNO), nor forced oscillation technique (FOT) differed significantly between patients with and without OSAS, and apnea hypopnea index was not significantly correlated with respiratory function, FeNO or FOT parameters.Conclusion:We conclude that even though BA patients with OSAS had good respiratory function, their BA was more severe than that of patients without OSAS, suggesting that OSAS may exacerbate BA. Background factors and asthma parameters were not predictive of PSG results, and patients with suspected OSAS should be evaluated proactively by using PSG.

A prospective observational study to assess PD-L1 expression in small biopsy samples for non-small-cell lung cancer.

BACKGROUND: Programmed cell death-1 (PD-1) immune checkpoint inhibitor antibody has proven to be effective in advanced non-small cell lung cancer (NSCLC) patients positive for programmed cell death-1 ligand-1 (PD-L1). However, there are currently no prospective studies evaluating PD-L1 expression for small biopsy samples. METHODS: To prospectively investigate the reliability of small samples for NSCLC, we included patients who underwent diagnostic biopsy by flexible bronchoscopy, computed tomography (CT) and ultra-sonography (US) guided core-needle to determine the PD-L1 expression status. In pathologically confirmed NSCLC, PD-L1 expression was evaluated using companion diagnostic PD-L1 immunohistochemistry. We evaluated: 1) tumor cell count and sample size, 2) tumor proportion score (TPS): <1, 1-49%, 50%≦, and 3) the concordance rate of TPS by biopsy and surgical samples. RESULTS: Of the 153 cases of PD-L1 expression, 110 were assessed using endobronchial ultrasonography guided transbronchial biopsy (EBUS-TBB) (thin bronchoscopy 84 cases; normal bronchoscopy 26 cases), 23 were endobronchial ultrasonography guided transbronchial needle aspiration (EBUS-TBNA), and 20 cases of CT or US-guided core-needle biopsy. Tumor cell count and sample size were significantly larger for normal bronchoscopy than thin bronchoscopy or EBUS-TBNA samples. Moreover, tumor cell counts for each subsequent biopsy decreased. In all cases, TPS distribution (undiagnosed, <1%, 1-49, 50%≦) was 2.6, 34.6, 31.4, 31.4%, respectively. TPS positive cases using thin bronchoscope was 55.9%, normal bronchoscope was 73.1% and EBUS-TBNA was 78.3%. In early stage adenocarcinoma, TPS was lower compared with advanced stages. Conversely, in squamous cell carcinoma, the rates of TPS were similar regardless of stage. The concordance rate of TPS by biopsy and surgical materials was 86.7%. CONCLUSION: Utilizing smaller samples for evaluation, the frequency of TPS was comparable to past clinical trials using larger samples. The differences in TPS were influenced by diagnostic tools, cancer histologic types and staging. The concordance of TPS between EBUS-TBB samples and surgical materials was high. TRIAL REGISTRATION: This study was performed at the Department of Respiratory Medicine at St. Marianna University School of Medicine Hospital, with ethics approval (#3590) and registered as a clinical trial ( UMIN000027030 ).

Probe-based confocal laser endomicroscopy for rapid on-site evaluation of transbronchial biopsy specimens.

BACKGROUND: Probe-based confocal laser endomicroscopy (pCLE) is a novel, noninvasive technology that provides real-time lung imaging during bronchoscopy. pCLE shows the elastic fiber network without the use of a fluorescent dye. Elastic fibers produce argon laser-induced autofluorescence at a wavelength of 488 nm, but tumor cells do not produce autofluorescence at this wavelength. As a result, the tumor cells cannot be observed directly. Therefore, we stained transbronchial biopsy (TBB) specimens with acriflavine to evaluate the benign and malignant structures using pCLE of ex vivo samples and to determine whether rapid histopathological diagnosis of TBB specimens could be made via pCLE. METHODS: After bronchoscopy, 36 TBB specimens were stained with acriflavine and observed using pCLE. Benign and malignant lesions were classified by cell density and nuclear magnitude disparity. RESULTS: We defined the confocal laser endomicroscopic atypia classification from the findings of the cells. The sensitivity for malignancy was 91.3%, and the specificity was 76.9%. Both inter-observer (κ = 0.48) and intra-observer (κ = 0.57) agreement confirmed moderate agreement. CONCLUSION: pCLE with acriflavine staining was useful to differentiate malignant from benign TBB specimens, and might be useful as a substitute for rapid on-site evaluation of histopathological diagnosis.

Bronchial Occlusion with Endobronchial Watanabe Spigot for Hemoptysis in a Mechanically Ventilated Patient with Extracorporeal Circulation.

Bronchial occlusion with endobronchial Watanabe spigots (EWSs) can be an essential therapeutic measure for treating massive hemoptysis in intensive care patients when no other conventional options are available. A 68-year-old-man on mechanical ventilation and extracorporeal circulation after cardiovascular surgery presented massive hemoptysis. He was deemed unfit for bronchial artery embolization (BAE) and surgery while in the intensive care setting; thus, bronchial occlusion was performed using EWSs. His hemoptysis ceased, and he was successfully weaned from mechanical ventilation and extracorporeal circulation. Bronchial occlusion by EWSs may be considered an optimal, and at times, definitive treatment for obtaining hemostasis in these situations.

Radiofrequency spectral analysis of EBUS for peripheral pulmonary lesions.

BACKGROUND AND OBJECTIVE: We previously reported that histogram-based quantitative evaluation for endobronchial ultrasonography (EBUS) B-mode images could differentiate between benign and malignant lesions. However, these images were generated from reconstructed raw radiofrequency (RF) signals and had some limitations. Currently, there are no reports on raw RF signal data to quantitatively differentiate ultrasound information for peripheral pulmonary lesions. METHODS: We prospectively hypothesized that RF spectral analysis from EBUS images could reveal sonographic features of peripheral pulmonary diseases. RF data were imported into a frequency spectral analysis software programme, comparing four parameters: mean frequency (MHz); slope; mid-band fit (dB); and y-intercept (dB), to differentiate between benign and malignant lesions. Furthermore, we compared subgroup analysis within benign and malignant lesions. RESULTS: RF data from EBUS images were obtained in 146 cases, of which, 106 lung cancers and 40 inflammatory diseases were present. Significant differences were observed for three parameters in benign and malignant lesions (mean frequency: P < 0.05, slope: P < 0.05, y-intercept: P < 0.01) with diagnostic accuracy of 61%, 57.5%, 63%, respectively. In subgroup analysis, the acute pneumonia group showed higher mean frequency, higher slope and lower y-intercept patterns compared to mycobacterial and fibrotic diseases (P < 0.05). In malignant lesions, small cell carcinoma showed higher mean frequency, higher slope and lower y-intercept pattern compared to other histopathological lung cancers (P < 0.01). CONCLUSION: RF analysis might be capable of demonstrating aspects of the lesion's pathological heterogeneity rather than precisely differentiating between benign and malignant lesions.

3D-measurement of tracheobronchial angles on inspiratory and expiratory chest CT in COPD: respiratory changes and correlation with airflow limitation.

Purpose: To assess tracheobronchial angles and their changes on combined inspiratory and expiratory thoracic computed tomography (CT) scans and to determine correlations between tracheobronchial angles and several indices of chronic obstructive pulmonary disease (COPD). Materials and methods: A total of 80 smokers underwent combined inspiratory and expiratory CT scans. Of these, 65 subjects also performed spirometry and 55 patients were diagnosed with COPD. On CT scans, 3-dimensinal tracheobronchial angles (trachea-right main bronchus [RMB], trachea-left main bronchus [LMB], and RMB-LMB) were automatically measured by software. Lung volumes at inspiration and expiration were also automatically calculated. Changes in tracheobronchial angles between inspiration and expiration were assessed by the Mann-Whitney test. Correlations of the angles with lung volume, airflow limitation, and CT-based emphysema index were evaluated by Spearman rank correlation. Results: The trachea-LMB angle was significantly smaller and the RMB-LMB angle was significantly larger at expiration than inspiration (P<0.0001). The trachea-LMB and RMB-LMB angles were significantly correlated with lung volume, particularly at expiration. The RMB-LMB angle was significantly correlated with airflow limitation and CT emphysema index (P<0.001-0.05) at inspiration and expiration, suggesting that narrowed RMB-LMB angle indicates more severe airflow limitation and larger extent of emphysema. Conclusion: Tracheobronchial angles change during respiration and are correlated with severity of COPD and emphysema.

Pulmonary Perfusion Using Intrabronchial Capnography in Pulmonary Artery Stenosis.

Stenting at the flow-limiting segment can improve the ventilation-perfusion ratio in patients with central airway stenosis. However, there is no quantitative examination for assessing the perfusion status during interventional bronchoscopy. Intrabronchial capnography can estimate regional gas exchange by measuring carbon dioxide concentration. We herein report a case of bilateral bronchial stenosis where stenting was able to improve ventilation-perfusion ratio using intrabronchial capnography. A 44-year-old man was admitted to our institution with orthopnea. Chest computed tomography showed an extrinsic compression at the bilateral main bronchus and right pulmonary artery due to a mediastinal mass. After introduction of general anesthesia, arterial oxygen tension suddenly decreased in the supine position. After initial stenting, an increase was seen in ventilation at the right lung; however, a ventilation-perfusion mismatch occurred due to an increase in dead-space ventilation at the right pulmonary artery stenosis. Intrabronchial capnography was an effective modality to confirm the regional perfusion status during interventional bronchoscopy in real time.

Sterilized talc pleurodesis for malignant pleural effusions: a Phase II study for investigational new drug application in Japan.

BACKGROUND: Malignant pleural effusion is a commonly seen complication of malignancies such as lung and breast cancers. In Western countries, talc is frequently used as a standard therapeutic agent (pleurodesis agent) with the aim of alleviating symptoms including dyspnea and chest pain. Talc is not recognized as a pleurodesis agent in Japan. The aim of this study was to verify the efficacy and safety of sterilized talc (NPC-05) for the introduction of talc in Japan. METHODS: The study was a single-arm, open-label, investigator-initiated trial conducted jointly at six institutions. The subjects were 30 patients with malignant pleural effusions. A solution of 4 g NPC-05 suspended in 50 ml physiological saline was instilled into the pleural space to perform pleurodesis. RESULTS: The efficacy of NPC-05 for pleural adhesion 30 days after pleurodesis was 83.3% (25/30 cases). Amelioration of dyspnea and pain (chest pain) was seen. Commonly seen adverse effects were increased C-reactive protein (CRP) and fever. Nearly all adverse events were phenomena previously reported as adverse effects of talc. No acute respiratory distress syndrome (ARDS) or other serious side effects occurred. CONCLUSION: The efficacy and safety of NPC-05 for malignant pleural effusion in Japanese patients was verified, and the clinical outcomes with talc were confirmed to be the same as previously reported in other countries. There is thought to be a high level of need for this agent in the treatment of malignant pleural effusion in Japan.

Differences in skeletal muscle loss caused by cytotoxic chemotherapy and molecular targeted therapy in patients with advanced non-small cell lung cancer.

BACKGROUND: Recent studies have revealed a reduction in the skeletal muscle area in patients with advanced non-small cell lung cancer (NSCLC) after chemotherapy. EGFR and ALK tyrosine kinase inhibitor (TKI)-based therapies are less cytotoxic than chemotherapy, but differences in skeletal muscle mass between patients receiving EGFR and ALK TKI therapies and patients receiving cytotoxic chemotherapy have not yet been reported. METHODS: Data of pathologically proven NSCLC patients were reviewed, and chest computed tomography and/or positron emission tomography-computed tomography images obtained from January 2012 to December 2014 were selected. Patients were divided into two groups: cytotoxic chemotherapy (CG) and molecular targeted (MG). Muscle mass was measured with a single cross-sectional area of the muscle at the third lumber vertebra (L3MA). To estimate skeletal muscle changes during chemotherapy, we defined the following L3 skeletal muscle index (L3SMI) ratio: post L3SMI/pre L3SMI. Differences in the SMI ratio between the groups were evaluated using the Wilcoxon signed-rank test. RESULTS: Sixty-five patients were included in this study: 44 patients received cytotoxic chemotherapy and 21 received molecular targeted therapy (EGFR and ALK TKI). The loss of L3MA in the CG was higher than in the MG (P = 0.03). In the CG, the L3SMI ratio defined to evaluate skeletal muscle mass changes was significantly lower than in the MG (P = 0.0188). CONCLUSION: Our results suggest that skeletal muscle loss during first-line therapy was significantly different between patients receiving cytotoxic chemotherapy and those receiving TKIs. Specifically, skeletal muscle loss was lower in patients receiving TKIs than in patients receiving cytotoxic chemotherapy.

Assessment of Bronchial Obstruction Using Lateral Pressure Measurement during Bronchoscopy.

BACKGROUND: In patients with bronchial obstruction estimating the location of the maximal obstruction is crucial for guiding interventional bronchoscopy. However, flow-volume curves cannot discriminate between the right and left lungs. OBJECTIVES: The aim of this study was to physiologically evaluate bronchial obstruction during interventional bronchoscopy. METHODS: We prospectively measured lateral airway pressure (Plat) at either side of the obstruction using a double-lumen catheter (pressure-pressure [P-P] curve) simultaneously to assess the degree of bronchial obstruction in 22 patients. The shape of the P-P curve was assessed to confirm the site of maximal obstruction. RESULTS: In the experimental study, Plat was uniform between both bronchi in the normal model. For the unilateral and bilateral obstruction models, a phase shift was only seen for the more obstructed side. In healthy subjects, the angle of the P-P curve was close to 45° and linear in shape. In patients with bronchial obstruction, the angle was much smaller but approached 45° after the bronchoscopic procedure. The degree of bronchial obstruction was significantly correlated with the angle of the P-P curve (r = -0.51, p < 0.01). Dyspnea significantly increased when the airway lumen was obstructed by more than 60% (p < 0.0001), and when the P-P curve appeared loop-shaped (p < 0.01). CONCLUSIONS: The shape of the P-P curve could be used to detect the site of maximal obstruction for the optimal positioning of the stent and assess the need for additional procedures in real time in patients with bronchial obstruction.

Comparison of Airway Measurements for Tracheobronchial Stenosis Between Stereoscopic Bronchoscope and MD-CT.

BACKGROUND: Stereoscopic bronchoscopy is a new diagnostic tool to measure the diameter and cross-sectional area of the airway. The stereoscopic bronchoscope, which operates the same as a standard bronchoscope, utilizes 2 lenses to measure the airway using the principles of triangulation. Furthermore, the stereoscopic bronchoscope has the capability to measure the size of the airway during intervention in real-time, including variable stenosis. MATERIALS AND METHODS: To prospectively compare preoperative stereoscopic and multidetector computed tomography (MD-CT) images to select the appropriate stent size for airway stenosis. Stereoscopic and MD-CT images were then measured to confirm the correct placement of the stent. RESULTS: Airway stenting was performed on 21 consecutive patients of whom, 15 were diagnosed with malignant and 6 with benign diseases. In total, 165 measurements were taken (134 healthy; 31 affected). For the diameter, Bland-Altman plots were used to measure data from 165 matched stereoscopic and MD-CT measurement sites (bias, 0.40±2.86 mm SD; percentage error, 33%), 134 healthy sites (bias, 0.554±2.83 mm SD; percentage error, 34%), and 31 affected sites (bias, 1.20±2.67 mm SD; percentage error, 52%). For the cross-sectional area, matched stereoscopic and MD-CT measurements were analyzed for 65 sites (bias, -10.53±92.85 mm SD; percentage error, 89%), 49 healthy sites (bias, -9.88±39.00 mm SD; percentage error, 32%), and 16 affected sites (bias, -13.12±48.81 mm SD; percentage error, 92%). CONCLUSION: Stereoscopic bronchoscopy was able to accurately measure the size of the airway during intervention, to assist in selecting the appropriate size of the stent.

Efficacy of long-term omalizumab therapy in patients with severe asthma.

BACKGROUND: The efficacy of omalizumab, an anti-immunoglobulin E (IgE) antibody, has been studied in patients with severe bronchial asthma. We conducted a study to evaluate, on the basis of both objective and subjective measures, the efficacy of omalizumab as a long-term therapy in patients with severe and persistent asthma. METHODS: Omalizumab was administered subcutaneously every two or four weeks. The results of pulmonary function tests, Asthma Control Test (ACT) and Asthma Health Questionnaire (AHQ)-33 scores, the dosage of methylprednisolone during the 12-month treatment period, and the number of emergency visits prior to the start of treatment with omalizumab were compared in patients pre- and post-treatment with omalizumab. RESULTS: Fourteen patients were enrolled in the study between June 2010 and February 2012. Ten patients completed the study. With omalizumab treatment, there was no improvement in lung function; however, the number of emergency visits (19.3 before treatment vs. 1.2 after treatment, p=0.020) and the dosage of methylprednisolone (871.5mg before treatment vs. 119.0mg after treatment, p=0.046) decreased significantly. ACT and AHQ-33 scores at 16 weeks after treatment were significantly better than baseline scores. Four patients continued treatment with omalizumab for four years, and a reduction in their corticosteroid usage was noted. CONCLUSIONS: Long-term omalizumab therapy in our patients was found to significantly reduce corticosteroid usage and the number of emergency visits. Long-term omalizumab therapy was effective and might have potential to reduce the frequency of asthma exacerbations. The trial has not been registered because it is not an intervention study.

Regional Lung Sound Asynchrony in Chronic Obstructive Pulmonary Disease Patients.

BACKGROUND: Regional lung sound distribution in chronic obstructive pulmonary disease (COPD) is reported to be asynchronous. Mathematical analyses using vibration response imaging (VRI), such as left and right lung asynchrony (gap index; GI) and regional lung asynchrony (asynchrony score; AS), are useful measures to evaluate lung sound asynchrony. OBJECTIVES: The aim of this study was to investigate the association of lung sound asynchrony with pulmonary functions and emphysematous lesions in COPD patients. METHODS: VRI recordings and pulmonary function tests were performed in 46 stable male COPD patients and in 40 healthy male smokers. Lung sound asynchrony was evaluated using GI, AS of the left and right lung (AS L-R), and AS of the upper and lower lung (AS U-L). In 38 patients, computed tomography taken within 6 months was available and analyzed. RESULTS: AS L-R and AS U-L were significantly higher in COPD patients than in healthy smokers, with no significant difference in GI. There were no significant correlations with either AS and pulmonary functions, excluding a negative correlation between AS U-L and diffusion capacity. Although there were no significant correlations between both AS and severity of emphysema, significant positive correlations were observed between heterogeneity of emphysematous lesions and AS L-R (ρ = 0.38, p < 0.05) or AS U-L (ρ = 0.51, p < 0.005). CONCLUSIONS: Regional lung sounds are distributed more asynchronously in COPD patients than in healthy smokers, which correlates with the heterogeneous distribution of emphysematous lesions.

Choke point physiology in airway stenting: A case presentation and discussion.

BACKGROUND: The point in the airway that allows the smallest maximal flow is known as the "choke point". The tube law describes the velocity of the expired air, which cannot exceed the wave-speed. Flow limitation during forced expiration is affected by the relationship between the transmural pressure (Ptm) and cross-sectional area (A) of the airway. Wave speed is dependent on the stiffness of the airway wall, as well as on the cross-section of the airway itself (dA/dPtm). METHODS: Airway stenting at the wave-speed, flow-limiting segment (choke point) is assessed by using a catheter, via the working channel of a stereoscopic bronchoscope, to measure the difference between lateral pressure and pleural pressure. RESULTS: Based on the wave-speed concept of maximal expiratory flow limitation, stenting at the choke point increased the cross-sectional area and supported the weakened airway wall, thus improving expiratory flow limitation and relieving dyspnea. CONCLUSION: To ensure correct stent positioning and thus optimal functional benefit, it is important to locate the exact position of tracheobronchial stenosis.

[Bronchoscopic treatments for COPD].

Several non-surgical and minimally invasive bronchoscopic interventions, such as bronchoscopic lung volume reduction (BLVR) techniques, have been developed to treat patients with severe chronic obstructive pulmonary disease (COPD). BLVR has been studied for treatment in severe COPD patients with emphysema. BLVR with one-way endobronchial valves is reported to be effective for patients with a heterogeneous emphysema distribution and without inter-lobar collateral ventilation. For the patients with collateral ventilation, and for the patients with homogeneous emphysema, BLVR with lung volume reduction coil has shown promising results. Targeted lung denervation(TLD) is a novel bronchoscopic intervention based on ablation of parasympathetic nerves surrounding the main bronchi. TLD seems to be effective for COPD with chronic bronchitis phenotype. This review gives a general overview of BLVR with one-way valve and lung volume reduction coil, and TLD.

A Novel Technique for the Placement of Endobronchial Watanabe Spigots Into the Bronchus: Side-Grasping Method.

BACKGROUND: Bronchial occlusion with an endobronchial Watanabe spigot (EWS) is effective for the management of persistent pulmonary air leaks; however, an optimal procedure for placing the spigot at the target bronchus remains debatable. The procedure most currently applied involves grasping the middle of the graspable part of the EWS with grasping forceps (conventional method). In this study, we assess a new technique, the side-grasping method, to maneuver the spigot into the target bronchus by using rotatable biopsy forceps to grasp the edge of the graspable part of the EWS. The aim of this study is to evaluate the effectiveness of this new technique for the simple placement of the EWS. METHODS: To compare the number of bronchoscopists who were able to place the EWS correctly within 10 minutes, and the time needed to place each spigot for both methods into 4 canine bronchi. RESULTS: More bronchoscopists correctly placed the EWS within 10 minutes using the side-grasping method compared with the conventional method (35/40 vs. 15/40, P<0.01). The total time needed to place spigots into all bronchi using the side-grasping method was 13±2.2 minutes versus 27.8±3.6 minutes using the conventional method (P<0.01). CONCLUSION: The side-grasping method described in this study was a simple and effective technique for correctly placing an EWS spigot into the target bronchus.

Quantitative Computed Tomography Measurement of Tracheal Cross-Sectional Areas in Relapsing Polychondritis: Correlations with Spirometric Values.

BACKGROUND: Although tracheal stenosis occurs in relapsing polychondritis (RP), no studies exist that have clarified correlations between quantitative airway measurement and spirometry in RP patients. OBJECTIVES: The aim of this study was to investigate correlations between the cross-sectional area (CSA) of the trachea and spirometric values in patients with RP. METHODS: The institutional review board approved this retrospective study, and written informed consent was waived. Twenty-six patients with RP underwent spirometry and chest computed tomography (CT) at full inspiration and end-expiration. On inspiratory and expiratory chest CT images, CSA at the intrathoracic trachea was measured for all CT slices, and the mean and minimum tracheal CSA were obtained. Correlations between the tracheal CSA and spirometric values were assessed by Spearman's rank correlation analysis. Results: Tracheal CSA measurements for inspiratory and expiratory scans were significantly correlated with FEV 1 , FEV 25-75% , and peak flow values (ρ = 0.51-0.86, p <0.01). During each inspiratory or expiratory phase, the minimum tracheal CSA achieved a higher correlation coefficient with spirometric values than the mean CSA. CONCLUSION: Tracheal dimensions for both inspiratory and expiratory CT are significant predictors of pulmonary function in patients with RP. The narrowest tracheal dimension likely determines the severity of airflow limitation in RP.