Bronchoscopy in some tertiary grade A hospitals in China: two years' development.

BACKGROUND: Although bronchoscopy has been widely performed in China, little has been known about its current state and development. In order to investigate the clinical application of bronchoscopy and make instructions for future education and development, the Chinese Society of Respiratory Diseases conducted postal surveys in both 2008 and 2010 in China. METHOD: Questionnaires were sent to 40 tertiary grade A hospitals in 2008 and 58 tertiary grade A hospitals in 2010 to investigate bronchoscopies performed in 2007 and 2009 respectively. RESULTS: Thirty (75%) hospitals returned the completed questionnaires in 2008 and forty-one (71%) hospitals in 2010. All the respondents possessed flexible bronchoscopes. Fifty percent of the respondents had less than five in 2007, while more than 50% of the respondents had 5-9 bronchoscopes in 2009. All the respondents performed a radiograph or CT scan before bronchoscopy. Percentage of general anesthesia and no pre-medication before bronchoscopy increased, while atropine usage decreased in 2009 compared to 2007. During bronchoscopy, pulse oximetry was the most widely used monitoring method. Most respondents used the nasal route to perform routine bronchoscopy. After the procedure, they used sinks to wash and glutaraldehyde to disinfect the bronchoscopes. The total number of flexible bronchoscopies performed during 2007 was 37 874 and the average was 1262. Whereas in 2009, the total number was 60 178 and the average was 1468. Diagnostic bronchoscopy was more widely used than therapeutic bronchoscopy. The mortality rate was 0.076‰ in 2007 and 0.032‰ in 2009. CONCLUSIONS: The two surveys, to some extent, reflected the current status and development of bronchoscopy in China. The results are worthy of future education and developing of new guidelines. Regular surveys and monitoring of bronchoscopies across China are needed.

Pseudomembranous necrotizing tracheobronchial aspergillosis: an analysis of 16 cases.

BACKGROUND: In our clinical practice we have been attracted by a group of patients with airway aspergillosis who have airway obstruction; we termed the condition as pseudomembranous necrotizing tracheobronchial aspergillosis (PNTA). In this study we analyzed the clinical data from patients with PNTA, so as to guide the diagnosis and treatment of the disease. METHODS: A total of 16 PNTA patients were treated in Changhai Hospital from January 2000 to January 2009. Their clinical data, including the demographic information, clinical symptoms, imaging findings, bronchoscopy findings, treatment strategies and efficacy, and prognosis, were retrospectively analyzed. RESULTS: All 16 patients were found to have primary systemic immunodeficiency diseases and/or damage of the focal airways. Nine patients (9/16, 56.3%) had pulmonary and tracheobronchial tumors, 5/16 (31.3%) had tracheobronchial involvement secondary to non-pulmonary tumors, and 2/16 (12.5%) had lung transplantation. The most common causes of PNTA included local radiotherapy (10/16, 62.5%), repeated chemotherapy (7/16, 43.8%) and recurrent intervention therapy by bronchoscope (4/16, 25.0%). Aspergillus fumigatus was the most frequent pathogen (62.5%, 10/16). The main clinical manifestations included progressive dyspnea (14/16, 87.5%) and irritable cough (12/16, 75.0%). The trachea was involved in 9/16 patients (56.3%), right main bronchus in 10/16 (62.5%). All 16 patients were treated with systemic anti-aspergillosis agents, local anti-aspergillosis agents with amphotericin B inhalation and direct perfusion of amphotericin B by bronchoscope, and interventional treatment by bronchoscope to ensure an unobstructed airway. The total efficiency was 31.3%. CONCLUSIONS: PNTA is an infectious disease caused by aspergillus and it mainly involves the trachea, primary bronchus and segmental bronchus. A. fumigatus is the most common pathogen. PNTA can pose a severe clinical threat and often occurs after systemic immunodeficiency and/or local airway damage, with the main symptoms including dyspnea and irritable cough. Bronchoscopic findings supply the main evidence for diagnosis of PNTA. Treatment of PNTA is difficult and requires a long course. Systemic and local anti-aspergillosis agents plus bronchoscopy debridement can improve the prognosis of the disease.

Paraneoplastic syndrome mimicking adult-onset Still's disease caused by advanced lung cancer: a case report.

BACKGROUND: Paraneoplastic syndromes (PNSs) are common complications of lung cancer and often develop preceding the diagnosis of primary malignancy. Rheumatologic PNSs mimicking Adult-Onset Still' s Disease (AOSD) is a rare condition with only a limited number of cases reported in the literature, none of which was associated with lung cancer. It is often difficult to differentiate AOSD-like paraneoplasia from coincidental AOSD based on the clinical manifestations. CASE PRESENTATION: Here we present a 56-year-old man with advanced lung adenocarcinoma who developed a remittent fever together with pharyngodynia and joint pain after first cycle of chemotherapy with paclitaxel plus carboplatin. Although a leukocytosis was detected, no evidence of infection was acquired and empirical antibiotic treatment was ineffective. A temple skin rash, abnormal hepatic function and a remarkable elevated level of serum ferritin occurred later in this patient, which highly supported a potential diagnosis of AOSD. The patient was finally diagnosed as AOSD-like PNS considering the good and prompt response to a short-term administration of non-steroidal anti-inflammatory drug and subsequent cycles of effective chemotherapy with pemetrexed plus cisplatin. DISCUSSION AND CONCLUSIONS: Though rare, AOSD-like PNS can be one of the potential diagnoses in lung cancer patients with fever of undetermined origin, especially those having no response to antibiotic treatment. Management consists of control of the underlying malignancy and symptomatic treatment of the syndromes with non-steroidal anti-inflammatory drugs or corticosteroids.

[Therapeutic efficacy analysis of bronchoscopic interventional therapy on severe tuberculous main bronchial stenosis complicated with unilateral atelectasis].

OBJECTIVE: To observe the therapeutic efficacy of bronchoscopic interventional therapy on severe tuberculous main bronchial stenosis or atresia complicated with unilateral atelectasis. METHODS: Ninety patients with severe tuberculous main bronchial stenosis or atresia complicated with unilateral atelectasis, who had received bronchoscopic interventional therapy, were divided into group A and B according to whether stents had been implanted or not. Patients in group A had been treated with electrocautery, balloon dilatation and cryotherapy. Group B had been treated with metallic stent implantation on the basis of the above interventional management. In order to observe the effectiveness, the time needed for taking effect and restenosis rate were noted. The efficacy between patients with different disease courses, radiology, bronchoscopy and dyspnea index were evaluated before treatment and after the patients' conditions were stable. RESULTS: Three months after treatment, the good response rate and the total effective rate of group B were higher than those of group A, 97% vs 42% (χ(2) = 29.595, P < 0.05), 100% vs 81% (χ(2) = 6.060, P < 0.05), respectively. The time needed for taking effect in group B was significantly shorter than that in group A, 0.25 month vs 1.6 month. The dyspnea indexes of both groups were significantly improved after treatment, but the improvement of group B was more significant than that of group A (u = -2.478, P < 0.05). The disease course of patients with different therapeutic efficacy was evaluated, and the median disease course was 2 months in good response efficacy patients, 3.5 months in improved patients, and 5 months in ineffective patients; the difference being significant between ineffective and good response efficacy patients (u = -3.079, P < 0.01). The restenosis rate of group B was significantly higher than that of group A, 72% vs 32% (χ(2) = 9.090, P < 0.01). The median restenosis time was 4 months in group A, and 6 months in group B. Bronchoscopy follow-up 12 months after the initial effective treatment showed that the good response rate and the total effective rate of group B were better than those of group A, 60% vs 29% (χ(2) = 10.559, P < 0.01), 88% vs 60% (χ(2) = 10.261, P < 0.01, respectively), and the total effective rate of main bronchial atresia patients in group B was significantly higher than that in group A, 90% vs 50% (Fisher's exact test, P < 0.05). There was no significant difference in effectiveness between severe stenosis and atresia patients in group A and B. CONCLUSION: Electrocautery, balloon dilatation, cryotherapy and stent implantation were effective methods to treat severe tuberculous main bronchial stenosis or atresia complicated with unilateral atelectasis. Among them, the therapeutic efficacy was better and the symptoms improved more quickly in patients with stent implantation. The efficacy of stent implantation was better than that of conventional interventional therapy, but the incidence of restenosis was also higher. Following-up should be emphasized in this group of patients. Disease courses were associated with the therapeutic efficacy; longer disease course was related to worse therapeutic efficacy, and restenosis occurred earlier. So interventional therapy should be initiated earlier for bronchial tuberculosis with dyspnea, especially for that complicated by atelectasis.

Dexamethasone protects airway epithelial cell line NCI-H292 against lipopolysaccharide induced endoplasmic reticulum stress and apoptosis.

BACKGROUND: Endoplasmic reticulum (ER) stress and ER stress-mediated apoptosis were reported to be involved in the pathogenesis of several diseases. In a recent study, it was reported that the ER stress pathway was activated in the lungs of lipopolysaccharide (LPS)-treated mice. It was also found that the C/EBP homologous protein (CHOP), an apoptosis-related molecule, played a key role in LPS-induced lung damage. The aim of this study was to verify whether LPS could activate the ER stress response in airway epithelial cells and which molecule was involved in the pathway. This study was also aimed at finding new reagents to protect the airway epithelial cells during LPS injury. METHODS: ER stress markers were observed in LPS-incubated NCI-H292 cells. SiRNA-MUC5AC was transfected into NCI-H292 cells. The effects of dexamethasone and erythromycin were observed in LPS-induced NCI-H292 cells. RESULTS: LPS incubation increased the expression of ER stress markers at the protein and mRNA levels. The knockout of MUC5AC in cells attenuated the increase in ER stress markers after incubation with LPS. Dexamethasone and erythromycin decreased caspase-3 activity in LPS-induced NCI-H292 cells. CONCLUSIONS: LPS may activate ER stress through the overexpression of MUC5AC. Dexamethasone may protect human airway epithelial cells against ER stress-related apoptosis by attenuating the overload of MUC5AC.

Pulmonary metastases 12 years after a mastectomy for borderline phyllodes tumor.

Phyllodes tumor is a rare breast tumor. A 45-year-old woman who underwent left mastectomy 12 years ago was found to have infiltrates in both lungs in a health examination. Combining histological examinations of the lung and breast samples, the diagnosis of borderline phyllodes tumor metastases to the lung was made. It is the longest interval to our knowledge that the metastases occurred 12 years after primary phyllodes tumor.

[Causes of benign central airway stenoses and the efficacy of interventional treatments through flexible bronchoscopy].

OBJECTIVE: To analyze the causes of benign central airway stenoses and to evaluate the efficacy of interventional treatments through flexible bronchoscopy. METHODS: Three hundred and eighty-six outpatients and inpatients with benign central airway stenoses in our hospital from January 1999 to December 2006 were retrospectively analyzed. Interventional treatments through flexible bronchoscopy were used to treat the benign central airway stenoses. The endoscopic interventional treatments included laser, electrocautery, argon plasma coagulation, cryotherapy, balloon dilation and stent insertion. Airway diameters, FEV1 and dyspnea index of patients were evaluated before and immediately after the last treatment procedure. RESULTS: The main causes of benign central airway stenoses were as follows: tuberculosis in 64.25% (248/386), secondary to prolonged orotracheal intubation or tracheotomy in 15.03% (58/386), injury in 3.63% (14/ 386) and inhalation burns in 3.11% (12/386), others were 54 cases. All the 386 patients received endoscopic interventional treatments. 89.89% (347/386) of the patients experienced improvement in dyspnea and cough. The average airway diameter increased from (2.49 +/- 1.57) mm to (6.41 +/- 1.70) mm (t = 47.427, P < 0.01). Dyspnea index decreased from 2.40 +/- 0.79 to 0.64 +/- 0.50 (t = 44.226, P < 0.01). The average value of FEV1 evaluated in 115 inpatients increased from (2.11 +/- 0.60) L to (3.46 +/- 0.75) L (t = 20.128, P < 0.01). Most patients needed multiple interventional treatments except 26 patients who received a single endoscopic treatment. Stable control of the diseases was achieved in 65.54% (253/ 386) patients 3 months after the last operation. CONCLUSION: Tuberculosis is the most common cause of benign central airway stenoses in this series. Utilization of interventional methods through flexible bronchoscopy is effective in treating benign central airway stenoses.

[Identification and bronchoscopic management of broncholithiasis].

OBJECTIVE: To report the diagnostic experience for broncholithiasis, and to evaluate the value of flexible bronchoscopic management for the disease. METHODS: The clinical data, radiological features, bronchoscopy findings, the effect and complications of bronchoscopic management in 31 patients with broncholithiasis admitted to changhai hospital of second military medical university and zhejiang Taizhou Hospital between 2000 and 2007 were retrospectively reviewed. RESULTS: There were 19 men and 12 women, the mean age was 58.6 +/- 12.6. There were 26 cases missed diagnosis, and 19 cases were misdiagnosis. The diagnosis was confirmed by chest CT combined with bronchoscopy in all the patients. Thirty-six broncholiths were revealed, of which 26 were intraluminal, 9 eroding in the bronchial wall, and 1 peribronchial. In 26 patients, 31 broncholiths were managed by flexible bronchoscope, and 25 broncholiths were successfully removed. The success rate for intraluminal free broncholiths was higher (23/25). One patient experienced hemoptysis of 300 ml after therapy, but no significant complications occurred in other patients. CONCLUSIONS: The diagnosis of broncholithiasis can be easily missed or misdiagnosed. Chest CT combined with bronchoscopy were useful methods for the diagnosis of the disease. Extraction of broncholiths with flexible bronchoscope is a safe and effective management, especially for intraluminal broncholiths.

[Clinical features and treatment of relapsing polychondritis with involvement of the respiratory tract-report of thirteen cases].

OBJECTIVE: To describe the clinical features and treatment of relapsing polychondritis with involvement of the respiratory tract. METHOD: Thirteen cases (admitted from Aug 2000 to Oct 2006) of relapsing polychondritis with involvement of the respiratory tract treated in our hospital were retrospectively analyzed. RESULTS: There were 9 males and 4 females, with ages ranging from 30 to 61 years (mean 50 years). At early stage of the disease, clinical manifestations included cough, throat pain and hoarseness. Patients in later stage usually complained of chest distress, shortness of breath and dyspnea. Severe complications were repeated lower respiratory tract infections and/or respiratory failure. Bronchoscopic examination revealed an edematous larynx, narrowing of the glottis, tracheobronchial edema, turgescence of bronchial cartilage rings and airway stenosis at early stage. At later stage of the disease, malacia of trachea and bronchi due to disappearance of bronchial cartilage rings, and partly obliteration of the both trachea and main bronchus on expiration were demonstrated. Thoracic CT scan, with three-dimensional reconstruction of the airways, demonstrated a diffusely thickened tracheobronchial wall with tracheobronchial stenosis in earlier period of the disease and showed severe narrowing of both trachea and main bronchi in later period. Lung function measurements showed a moderate obstructive ventilatory disorder in 5 patients. Medical treatment with corticosteroids and immunosuppressive drugs was given in 12 patients. Symptoms were improved in 6 patients in earlier period of the disease, however, 6 patients in later period were not relieved. Twelve self-expanding metallic stents were placed in the airways (trachea and/or main bronchi), and obstruction of the respiratory tract was relieved in 5 patients, but there was no improvement in 1 patient who later was treated with positive airway pressure support. The 13 patients were followed for 1 to 48 months, and 12 patients survived, but one patient died 2 years after diagnosis. CONCLUSIONS: Corticosteroid therapy is effective in improving the symptoms and delaying the progression of relapsing polychondritis with involvement of the respiratory tract at early stage. At later stage of the disease, airway interventional therapy, such as metallic stent placement, tracheostomy or positive airway pressure support, can be used to treat airway obstruction and to improve the survival.

[Clinical features of endotracheal/endobronchial metastases: analysis of 62 cases].

OBJECTIVE: To describe the clinical presentations, diagnosis and treatment of endotracheal/endobronchial metastases (EEM). METHODS: Retrospective and follow-up analyses were conducted for 62 cases of bronchoscopically confirmed EEM. Clinical staging, location in the tracheobronchial tree, the number of lesions, treatment and prognosis were analyzed. RESULTS: The most common neoplasms associated with EEM were breast cancer (17.7%), coronal cancer (17.7%), and esophageal carcinoma (14.5%). Most EEM patients presented with cough, hemoptysis, dyspnea, chest pain and fever. Abnormal changes on chest X-ray were found in 87.1% cases, and CT changes were found in all patients. A total of 76 intraluminal lesions were recorded, of which 19 in the trachea and 57 in the bronchus, including 31 in the right bronchus and 26 in the left bronchus. Type I EEM accounted for 28.9%; Type II, 23.7%; Type III, 14.5%, and Type IV, 32.9%. The median survival time was 9.8 months. There was significant difference in survival time between Type IV EEM and the other three types (P < 0.05). CONCLUSIONS: EEM may occur in the trachea or in the bronchus. Flexible bronchoscopy is a valuable tool for the diagnosis of EEM. Although there are cases of long survival, the prognosis of EEM is generally poor.

[Amiodarone pneumonitis with Hypermastigote lung infection: a case report and review of the literatures].

OBJECTIVE: To describe the clinical features of amiodarone pneumonitis with Hypermastigote lung infection. METHODS: Case report and review of the related literatures. The clinical symptoms, laboratory tests, radiographic patterns, diagnosis, and therapeutic management of amiodarone pneumonitis with Hypermastigote lung infection were described. RESULTS: A 58 year old male patient presented dyspnea after exertion. Pulmonary function showed decrease of the diffusing capacity, and CT showed interstitial changes and alveolar exudation. Foamy cells and Hypermastigotes were found in the bronchoalveolar lavage fluid. After cessation of amiodarone and the start of anti-parasite therapy, the symptoms relieved. CONCLUSIONS: Amiodarone pneumonitis with Hypermastigote lung infection is very rare. The infection may be due to decrease of local immunity caused by amiodarone pneumonitis.

[Restenosis and its management after metallic stents implantation in benign tracheal and main bronchial stenosis].

OBJECTIVE: To observe the occurrence of restenosis after metallic stents implantation in benign tracheal and main bronchial stenosis, and to evaluate the therapeutic effects of balloon dilatation, cryotherapy and electrocautery. METHODS: Thirty patients with benign tracheal stenosis and 35 patients with main bronchial stenosis caused by tuberculosis were treated with metallic stents implantation and a follow-up was carried out to observe the occurrence of restenosis. Combined balloon dilatation, cryotherapy and electrocautery were used to manage the restenosis. The lumen of stenotic segment, dyspnea index and pulmonary function were measured before management and after the patient's condition became stable. RESULTS: Restenosis occurred in 6 of the 30 patients receiving tracheal stenting and in 8 of the 35 patients receiving bronchial stenting, the restenosis rates were 20% and 22.86%, respectively. In total, 30 Chinese-made stents and 36 Ultraflex stents were implanted, and the restenosis rate was 20% and 22.2%, respectively (P > 0.05). The restenosis rate was 4/9 in the upper segmental tracheal stents, and was 9.09% in the middle-lower segmental stents (chi(2) = 5.114, P < 0.05, but chi(c)(2) = 3.100, P > 0.05). The restenosis rate was 16.67% in the fibrotic stage of endobronchial tuberculosis (EBTB), and was 60% in the inflammatory reaction stage of EBTB (chi(2) = 4.564, P < 0.05, but chi(c)(2) = 2.437, P > 0.05). The effective rate was 4/6 in the tracheal stenting restenosis patients, and was 2/4 and 2/2 in the upper and middle-lower segment groups, respectively. The effective rate was 7/8 in the bronchial stenting restenosis patients. After management, the lumen diameter of stenotic segment in the tracheal stenting restenosis patients increased from (3.33 +/- 1.63) mm to (9.33 +/- 3.98) mm (P < 0.02), the dyspnea index decreased from (3.67 +/- 0.52) to (1.50 +/- 1.64) (P < 0.02), the vital capacity (VC) increased from (1.39 +/- 0.17) L to (2.43 +/- 0.70) L (P < 0.01), the forced expiratory volume in one second (FEV(1)) increased from (1.02 +/- 0.15) L to (2.00 +/- 0.72) L (P < 0.02). After management, the lumen diameter of stenosis segment in the bronchial stenting restenosis patients increased from (3.00 +/- 0.76) mm to (7.38 +/- 2.00) mm (P < 0.001), the dyspnea index decreased from (1.63 +/- 0.52) to (0.50 +/- 0.76) (P < 0.005), VC increased from (1.74 +/- 0.16) L to (2.74 +/- 0.41) L (P < 0.001), FEV(1) increased from (1.41 +/- 0.19) L to (2.36 +/- 0.37) L (P < 0.001). CONCLUSION: Restenosis occurred in some patients with benign tracheal and tuberculous bronchial stenosis after metallic stent implantation. The restenosis rate was higher in the upper tracheal stenosis than that in the middle-lower tracheal stenosis. Caution should be taken when metallic stents are placed in this part of the trachea. The restenosis rate was higher in the inflammatory reaction stage of EBTB than in the fibrotic stage. Effort should be made to avoid placing metallic stents at this stage of the disease. Balloon dilatation, cryotherapy and eletrocautery are effective methods in managing restenosis after stent implantation.

[Relationship of plasma homocysteine and folic acid levels and 5,10-methylenetetrahydrofolate reductase gene mutation with venous thromboembolism].

OBJECTIVE: To investigate the association between concentrations of plasma homocysteine and folic acid, 5,10-methylenetetrahydrofolate reductase (MTHFR) C667T mutation and venous thromboembolism (VTE) and to analyze the effect of MTHFR C667T mutation on concentrations of plasma homocysteine and folic acid. METHODS: In 58 patients with VTE and 58 sex and age matched controls, epidemiological risk factors were surveyed. The concentration of plasma homocysteine was measured by high performance liquid chromatography, and the concentration of plasma folic acid was measured by radioimmunoassay. MTHFR C667T genotype was measured by PCR-RFLP. RESULTS: The concentrations of plasma homocysteine and folic acid showed significant difference between the case group and the control group (OR = 1.5, 95% CI: 1.216 - 2.213 and OR = 0.396, 95% CI: 0.149 - 0.709, respectively). There was no significant difference in the frequency of mutant alleles in site 667 of MTHFR gene between the cases and the controls (P > 0.05). The concentration of plasma folic acid was associated with the concentration of plasma homocysteine (multiple correlation coefficient = -2.061, P < 0.05). The MTHFR C667T polymorphism was associated with the concentration of plasma folic acid but not with the concentration of plasma homocysteine in both the case group and the control group. The multiple correlation coefficient between the MTHFR C667T polymorphism and the concentration of plasma folic acid is 0.5856 (P < 0.01). CONCLUSIONS: The results of our study demonstrate that hyperhomocysteinemia and folic acid deficiency are independent risk factors for VTE. Folic acid deficiency is a cause of hyperhomocystinemia while the MTHFR C667T mutation is one of the possible genetic factors causing folic acid deficiency in this Chinese population.

[Pulmonary epithelioid hemangioendothelioma. a case report and review of the literature].

OBJECTIVE: To describe the clinical features of pulmonary epithelioid hemangioendothelioma. METHODS: With a case report and review of the related literatures, the etiology, clinical manifestations, diagnosis, differential diagnosis, management and prognosis of pulmonary epithelioid hemangioendothelioma were described. RESULTS: The etiology of this rare disease remains unknown. Symptoms are scanty and usually mild; chest radiograph or computed tomography usually reveals multiple bilateral pulmonary nodules. Primitive lumen formed by a single cell is the pathologic feature. Immunohistochemical stains show that the malignant cells are of the endothelial type. There is no effective treatment for this disease and its prognosis is unpredictable. CONCLUSION: Pulmonary epithelioid hemangioendothelioma is rare and often misdiagnosed as other pulmonary diseases.