Computed tomography and bronchoscopy in chest radiographically occult main-stem neoplasm diagnosis and Nd-YAG laser treatment in 8 patients.

We studied 8 adult patients with variable symptoms of cough, dyspnea, stridor, wheezing, or hemoptysis. Fiberoptic bronchoscopy in all showed complete or nearly complete endobronchial obstruction of a main-stem bronchus by neoplasm with a mean bronchial diameter of 1.9 mm +/- 1.6 mm (mean +/- standard deviation). In 4 patients, a lobar bronchus was also completely obstructed. No mass was visible on chest radiographs of any patient; however, computed tomography in each showed main-stem endobronchial obstruction, lobar obstruction (4 instances in 3 patients), and in 6 patients hypoperfusion of the involved lung. Computed tomographic scan showed additional abnormalities that were unsuspected on viewing chest radiographs or at bronchoscopy, including mediastinal adenopathy in 3 patients and an extraluminal tumor component in 4. After therapy with Nd-YAG laser, main-stem airway diameter increased to a mean of 9.6 mm +/- 1.0 mm (P less than .05) and pulmonary functions improved. Results suggest the complementary role of computed tomography and fiberoptic bronchoscopy in the detection and laser-treatment planning of chest radiographically occult severe neoplastic obstruction of the main-stem bronchus.     

Virtual bronchoscopy and 3D spiral CT reconstructions in the management of patient with bronchial cancer--our experience with Syngo 3D postprocessing software

Multislice helical CT generated virtual bronchoscopy (VB) represents one of the most recent developments in three-dimensional computer aided visualisation techniques. VB allows non-invasive and relatively accurate 3D evaluation of tracheobronchal tree. We performed virtual bronchoscopy and in-space 3D volume analysis on CT-data set acquired from sixty-four-year old male with bronchial cancer in order to demonstrate advantages and disadvantages of these methods in diagnostics and preoperative management of metastatic bronchial cancer. Siemens Somatom Emotion 16 helical CT scanner was used for data acquisition. Data post-processing was done with 3D Syngo 2006G software package from Siemens medical systems. CT scanning of the thorax was performed in heavy smoker with an expansive T4N1M1 malignant process in a superior lobe of the right lung accompanied with large metastatic lesion attached on the right lateral chest wall. Metastatic lesions were also found in vertebral column. In-space 3D analysis followed with virtual bronchoscopy had revealed obstruction of apical branch of superior lobe segmental bronchus. External compression done by tumor to the superior segmental and right main bronchus was found. We concluded that multi-slice CT in connection with VB became a possible non-invasive alternative to bronchoscopy, if tissue samples are not required.     

实验猕猴肺部CT影像断层初步观察

目的应用CT技术对成年实验猕猴胸部肺窗进行断层扫描观察,探讨CT技术对猕猴肺部疾病的临床诊断意义,建立正常猴肺部CT断层扫描图谱,为CT技术在猕猴解剖学的研究、疾病的临床诊断及科学实验方面的应用,提供影像学的基础资料。方法经过触诊、叩诊、听诊、体温、呼吸率、心率、呼吸运动、血液常规等检查,选择健康猴10只,雌雄各半,年龄分别为5～10岁,进行肺部CT断层扫描检测。试验猴全身麻醉后,置于CT诊断床上,取头前尾后仰卧位进行肺部扫描,获取肺窗扫描图像。对具有解剖意义的扫描图像的每个层面的主要结构（肺叶、气管、动脉血管、静脉血管等）进行标注。结果 （1）获得具有解剖意义的肺窗扫描图像13张。（2）在断层扫描的图像中,肺、气管、较大血管等组织器官界面清晰。肺为左右两侧,左肺分为上叶、中叶、下叶,右肺分为上叶、中叶、下叶、奇叶四部分。不同的断层面分别可见肺部左主支气管、右主支气管、支气管、血管等组织。（3）肺部较小或细小的血管、神经组织界面不清晰。结论 （1）应用CT获得的正常猕猴胸部肺窗断层扫描图像表明,正常健康猴双肺纹理清晰,走行自然,肺野透光度良好,双肺无异常实质病变影像。（2）获得了健康猕猴肺部的CT影像学资料,为猕猴肺部疾病的诊断,提供了一种安全、方便又准确的新依据,建立了成年健康猕猴肺部CT断层解剖研究的背景资料。     

Lower lobe pulmonary tuberculosis in immunocompetent male

We present a case of 23-year-old student misdiagnosed for two months. Radiological finding showed a pneumonial infiltrate of left lung lower lobe. Antibiotical therapy was not resulting in a radiological regression. Biopsy of the lung infiltrate by transthoracic computed tomography guided histology needle, showed granulomatous inflammation with necrosis. Bronchial aspirate received by bronchoscopy was positive in culture on Mycobacterium tuberculosis. After 6 months of antituberculotic therapy advance the complete regression of lung infiltrate. Tuberculosis of lower lung lobe is difficult to diagnose, particularly in persons who are not immunocompromised or without associated diseases. Lower lobe localization of tuberculosis is between 0.6 to 10.5% in all cases. Early diagnosis and therapy of pulmonary tuberculosis depends on bronchoscopic samples. The biopsy of the lung infiltrate by transthoracic computed tomography guided histology needle in histopathological and bacteriological diagnosis of tuberculosis was also useful.     

Chemokine Localization in Bronchial Angiogenesis

Angiogenesis in the lung involves the systemic bronchial vasculature and becomes prominent when chronic inflammation prevails. Mechanisms for neovascularization following pulmonary ischemia include growth factor transit from ischemic parenchyma to upstream bronchial arteries, inflammatory cell migration/recruitment through the perfusing artery, and paracrine effects of lung cells within the left bronchus, the niche where arteriogenesis takes place. We analyzed left lung bronchoalveolar lavage (BAL) fluid and left bronchus homogenates after left pulmonary artery ligation (LPAL) in rats, immediately after the onset of ischemia (0 h), 6 h and 24 h later. Additionally, we tested the effectiveness of dexamethasone on decreasing inflammation (0–24 h LPAL) and angiogenesis at early (3 d LPAL; bronchial endothelial proliferation) and late (14 d LPAL; blood flow) stages. After LPAL (6 h), BAL protein, total inflammatory cells, macrophages, and polymorphonuclear cells increased significantly. In parallel, pro-angiogenic CXC chemokines increased in BAL and the left main-stem bronchus (CXCL1) or only within the bronchus (CXCL2). Dexamethasone treatment reduced total BAL protein, inflammatory cells (total and polymorphonuclear cells), and CXCL1 but not CXCL2 in BAL. By contrast, no decrease was seen in either chemokine within the bronchial tissue, in proliferating bronchial endothelial cells, or in systemic perfusion of the left lung. Our results confirm the presence of CXC chemokines within BAL fluid as well as within the left mainstem bronchus. Despite significant reduction in lung injury and inflammation with dexamethasone treatment, chemokine expression within the bronchial tissue as well as angiogenesis were not affected. Our results suggest that early changes within the bronchial niche contribute to subsequent neovascularization during pulmonary ischemia.     

Aerodynamic characteristics of the human right lung bronchial tree]

A new method of studying the aerodynamical characteristics of normal right bronchial tree in 17 natural preparations is described. The authors have found that 24 to 44 per cent of the total airflow entering the right main bronchus pass through the upper lobe bronchus, 9-26 per cent through the middle lobe bronchus and 38-56 per cent through the lower lobe bronchus. The data obtained show good agreement with the volume of the corresponding lobe expressed as percentage to the total right lung volume. Bronchial tree preparations differ greatly in their carrying capacities due to their corresponding aerodynamical resistances (+50% +25%). The relationship between resistance coefficient of the bronchial tree preparations and their geometrical parameters has been found.     

大咯血介入治疗失败的罕见原因：腹腔动脉系统参与供血（附2例报告及文献复习）

目的：咯血的主要责任血管是支气管动脉,非支气管性体动脉参与供血是大咯血介入治疗失败的重要原因,腹腔动脉系统分支动脉参与供血更为罕见。本文通过收集相关病例,结合国内外相关研究,提高对腹腔动脉系统分支动脉为咯血责任动脉的认识,探讨其可能的病理机制、危险因素。方法：回顾分析2例腹腔动脉系统分支（胃左动脉、肝左动脉）参与大咯血供血动脉的临床及影像学资料,并报道介入栓塞治疗的效果。结果：2例患者均为支气管动脉栓塞后再发大咯血,再次血管造影显示1例肝左动脉参与供血,1例胃左动脉参与供血。栓塞上述血管后,患者止血成功。病变位于下肺、伴有胸膜增厚,提示有腹腔动脉系统分支动脉参与供血的可能。术前仔细阅读患者影像学资料,术前行主动脉分支动脉CT血管成像,可减少对责任性非支气管性体动脉的遗漏。结论：腹腔动脉系统参与供血是介入栓塞治疗后咯血复发的少见原因,了解其病理机制、危险因素,及时进行栓塞,可以降低咯血的复发率。     

Expiratory flow limitation in dogs with regional changes in lung mechanical properties

We examined maximum expiratory flow (Vmax) in two canine preparations in which regional changes in lung mechanical properties were produced. In one experiment serial bronchial obstructions were made to determine whether flow-limiting sites (choke points, CP) would occur in series. With the right lung tied off, constrictions were placed at the left lower lobar bronchus (LLL) and left main-stem bronchus. On deflation from total lung capacity, the obstructed LLL and nonobstructed left upper lobe (LUL) emptied into the obstructed left main-stem bronchus. Although a CP common to both lobes was identified at the main-stem obstruction, which limited total Vmax, we questioned whether there was also a CP at the lobar obstruction that fixed LLL flow. In that case the rate of LLL emptying would not be dependent on the presence of the common (i.e., central) CP and thus the flow contribution of the LUL. We found that when the LUL was removed, the LLL increased its rate of emptying. Thus a lobar CP did not fix LLL flow and CP did not occur in series. In a second experiment emphysema was produced in the left lung to reduce lung recoil, whereas the right lung was normal. CP were identified at approximately lobar bronchi of each lung, and the lungs were emptied at different rates. A CP common to both lungs was not identified. Our results indicate that in localized lung disease, if flows from the different regions are high enough, then wave speed is reached in proximal airways, and a CP occurs centrally rather than peripherally. On the other hand, if flows are low, then wave speed is reached peripherally and a CP common to all lung regions does not occur.     

The ventilatory patterns of the left upper lobe of lung

Having knowledge on models of the bronchial tree branching, is of a special interest for clinical and surgical pulmology, because the hemilobectomy, segmentectomy and subsegmentectomy are always determined by intralobar, intrasegmental and intrasubsegmental bronchial ramification. Investigations were performed on 100 lungs of children and adults of both sexes, one day to 85 years old, randomly chosen. There are two main types of branching of the left upper lobe bronchus: the bifurcation pattern as dominant model in 74% and the trifurcation model found in 26%. Out of 100 lungs studied, 21 lungs had the ventilatory variations of the bronchopulmonary segments. The classification and categorization of the ventilatory of bronchopulmonary segments of the left upper lobe of lung were made. This classification contains 5 categories and 8 subcategories.     

肺部感染对支气管封堵治疗影响的实验研究

目的:探讨肺部感染对支气管封堵治疗影响的动物实验性研究。方法:取健康杂种犬18条,分为3组(A、B、C组)(n=6),经支气管镜每只犬置入致密螺栓状支气管封堵器2枚,其中A、B组为肺部感染组,C组仅为单纯封堵(A、C组封堵后使用抗生素,而B组封堵后未使用抗生素)。观察实验动物的耐受性,定期复查血象、支气管镜、胸部CT扫描,8周后观察封堵器附近支气管组织及远端肺组织变化。结果:观察期内,除1例因给药管不慎封堵入靶支气管内而死亡外,其余犬耐受性良好;截至封堵第8周,36只封堵器中,脱落共有0只(0/36)。胸部CT扫描和组织病理学检查证实,部分封堵的肺叶有萎陷,封堵部位远端肺泡腔缩小,5例封堵部位及其周围有轻度阻塞性炎症改变,未出现肺脓肿及坏死。肺部感染因素对犬的恢复有延迟;而感染组术后肌注抗生素与否,并未能缩短实验动物的不适反应过程,亦未能预防或减少阻塞性炎症的发生。结论:试制的支气管封堵器置入方便,组织相容性好;无论单纯封堵还是肺部感染组的封堵,各组实验动物均有较好的耐受性,但是肺部感染因素对犬的恢复有延迟;肺部感染组术后肌注抗生素与否,对提高动物的耐受程度无明显作用。     

Reduction of lung perfusion increases VA/Q heterogeneity

This study addresses the hypothesis that decreases in lung perfusion rate independently worsen gas exchange efficiency in an isolated left lower lobe in zone 2 conditions. In seven anesthetized dogs, the left lower lobe was isolated, leaving the bronchus and bronchial vasculature intact. Blood was taken from the femoral arteries and reinfused at a controlled rate into the pulmonary artery of the left lower lobe. The flow rate was varied between 100 and 400 ml/min. The multiple inert gas elimination technique was used to quantitate the matching of ventilation to perfusion. Reduction in lobe blood flow resulted in a significant increase in perfusion-related indexes of alveolar ventilation-perfusion heterogeneity, such as the log standard deviation of the perfusion distribution, the retention component of the arterial-alveolar difference area, and the retention dispersion index. The increased heterogeneity suggests a worsening of the intraregional matching between the ventilation and the perfusion when perfusion is less than normal.     

Fibreoptic bronchoscopy today: a review of 255 cases.

An analysis of 255 fibreoptic bronchoscopies showed that the major indication for bronchoscopy was suspected bronchial carcinoma (93% of cases). Of the 183 patients finally shown to have bronchial carcinoma 83% had abnormal bronchoscopy findings and 65% had bronchial biopsy specimens diagnostic of malignancy. These figures were superior to those obtainable with rigid bronchoscopy, particularly with upper lobe and peripheral tumours. Brush biopsy and bronchography were useful supplementary techniques. Sputum cytology gave poorer results than fibreoptic bronchoscopy, but enabled diagnosis in some otherwise undiagnosed cases. The complication rate was low and the claim of this new technique to be the investigation of choice in bronchial carcinoma seemed to be justified in clinical practice.     

Cytomorphology of granular-cell tumor of the bronchus. A case report

The cytologic features of a bronchial granular-cell tumor clinically mimicking a bronchogenic carcinoma are presented. Distinctive granular cells similar to the main cellular components of the surgical specimen were found in abundance in bronchial brushings and washings obtained during bronchoscopy. Our findings and conclusions confirm previously published studies. Granular-cell tumors of the bronchus can easily be diagnosed on cytologic examination if the entity is considered in the differential diagnosis of clinically suspected lung tumors.     

Left and Right Lung Asynchrony as a Physiological Indicator for Unilateral Bronchial Obstruction in Interventional Bronchoscopy

Background

In patients with bronchial obstruction, pulmonary function tests may not change significantly after intervention. The airflow asynchrony in both lungs due to unilateral bronchial obstruction may be applicable as a physiological indicator. The airflow asynchrony is reflected by the difference in the left and right lung sound development at tidal breathing.

Objectives

To investigate the usefulness of left and right lung asynchrony due to unilateral bronchial obstruction as a physiological indicator for interventional bronchoscopy.

Methods

Fifty cases with central airway obstruction were classified into three groups: tracheal, bronchial and extensive obstruction. The gap index was defined as the absolute value of the average of gaps between the left and right lung sound intensity peaks for a 12-second duration.

Results

Before interventional bronchoscopy, the gap index was significantly higher in the bronchial (p<0.05) and extensive obstruction groups (p<0.05) than in the tracheal group. The gap index in cases with unilateral bronchial obstruction of at least 80% (0.18±0.04 seconds) was significantly higher than in cases with less than 80% obstruction (0.02±0.01 seconds, p<0.05). After intervention for bronchial obstruction, the dyspnea scale (p<0.001) and gap index significantly improved (p<0.05), although no significant improvements were found in spirometric assessments. The responder rates for dyspnea were 79.3% for gap indexes over 0.06 seconds and 55.6% for gap indexes of 0.06 seconds or under.

Conclusions

Assessment of left and right lung asynchrony in central airway obstruction with bronchial involvement may provide useful physiological information for interventional bronchoscopy.     

Evaluation of Hemoptysis in Patients With a Normal Chest Roentgenogram

Hemoptysis is a common presenting complaint in patients with pulmonary disease. Although controversial, many clinicians suggest that all patients with hemoptysis should be evaluated with bronchoscopy to exclude the presence of a serious pathologic condition. We reviewed records for an 18-month period, during which 113 patients had hemoptysis as their principal complaint. In all, 26 of the 113 patients had normal chest roentgenograms. All underwent bronchoscopy as part of their evaluations. Results of bronchoscopy in these patients neither altered therapeutic decisions nor led to diagnoses of specific pathologic processes. We conclude that close observation of patients with normal chest roentgenograms who have hemoptysis may be an acceptable clinical approach.     

The bronchial tree and blood vessels of the Japanese monkey lung

The author injected various colored celluloid solutions into the bronchial tree and blood vessels of the lungs of five adult Japanese monkeys (Macaca fuscata) in order to prepare cast specimens. These specimens were investigated from the comparative anatomical viewpoint to determine whether the bronchial ramification theory of the mammalian lung (Nakakuki, 1975, 1980) can be applied to the Japanese monkey lung or not. The bronchioles are arranged stereotaxically like those of other mammalian lungs. The four bronchiole systems, dorsal, ventral, medial, and lateral, arise from both bronchi, respectively, although some bronchioles are lacking. In the right lung, the bronchioles form the upper, middle, accessory, and lower lobes, while in the left lung, the upper and accessory lobes are lacking and bi-lobed middle and lower lobes are formed. In the right lung, the upper lobe is formed by the first branch of the dorsal bronchiole system. The middle lobe is the first branch of the lateral bronchiole system. The accessory lobe is the first branch of the ventral bronchiole system. The lower lobe is formed by the remaining bronchioles of the four bronchiole systems. In the left lung, the middle lobe is formed by the first branch of the lateral bronchiole system. The lower lobe is formed by the remaining bronchioles. Thus, the bronchial ramification theory of the mammalian lung applied well to the Japanese monkey lung. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole. It then runs along the dorso-lateral side of the right bronchus between the dorsal bronchiole system and the lateral bronchiole system. On its way, it gives off branches of the pulmonary artery which run along the dorsal or lateral side of each bronchiole except in the ventral bronchiole system. In the ventral bronchiole system, the branches run along the ventral side of the bronchioles. The distributions of the pulmonary artery in the left lung are the same as those in the right lung. The pulmonary veins do not always run along the bronchioles. Most of them run on the medial or ventral side of the bronchioles. Some of them run between the pulmonary segments. In the right lung, these pulmonary veins finally form the right upper lobe vein, right middle lobe vein and the right lower lobe pulmonary venous trunk before entering the left atrium. However, the right accessory lobe vein runs on the dorsal side of the bronchiole and pours into the right lower lobe pulmonary venous trunk. In four cases out of the five examples, part of the right lower lobe veins pour into the right middle lobe vein, while the others enter the right lower lobe pulmonary venous trunk. In the left lung, the branches of the pulmonary veins finally form the left middle lobe vein and the left lower lobe pulmonary venous trunk.     

A primary pulmonary sarcoma in a rhesus monkey after inhalation of plutonium dioxide

A pulmonary fibrosarcoma of bronchial origin was discovered in a Rhesus monkey that died of pulmonary fibrosis 9 years after inhalation of plutonium-239 dioxide and with a radiation dose to lung of 1400 rad (14 Gy). It grew around the major bronchus of the right cardiac lung lobe and extended into the bronchial lumen and into surrounding pulmonary parenchyma. It also readily invaded muscular pulmonary arteries, resulting in infarction and scarring in the right cardiac lobe. Despite this aggressive growth, the tumor did not metastasize. The primary cause of death was severe pulmonary fibrosis involving the alveolar septa and and perivascular and peribronchial interstitium. Bullous or pericitrical emphysema was prominent. The initial lung burden of plutonium in this monkey was 270 nCi (10 kBq) which is equivalent to approximately 500 times the maximum permissible lung burden for man on a radioactivity per unit body weight basis. The time-dose relationship for survival is consistent with that of dogs and baboons that inhaled plutonium dioxide and died with lung tumors.     

The bronchial tree,lobular division,and blood vessels of the lung of the silvered lutong (Presbytis cristata)

The lungs of three silvered lutongs (Presbytis cristata) were examined. The right and left lungs have the dorsal, lateral, ventral, and medial bronchiole systems, which arise from the corresponding sides of both bronchi, respectively. Bronchioles in the dorsal and lateral bronchiole systems are well developed, whereas those in the ventral and medial bronchiole systems are poorly developed and lack some portions. According to the fundamental structure of bronchial ramifications of the mammalian lung (Nakakuki, 1975, 1980), the right lung consists of the upper, middle, lower, and accessory lobes, whereas the left lung consists of a bilobed middle lobe and a lower lobe, in which the right upper lobe is extremely well developed. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then across the dorsal side of the right middle lobe bronchiole. Initially it runs along the lateral side of the right bronchus and then gradually comes to run along the dorsal side. During its course, it gives off branches which run mainly along the dorsal or lateral side of the bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole, and then follows the same course as that in the right lower lobe. The pulmonary veins run medially or ventrally to the bronchioles, and finally enter the left atrium as four or five large veins.     

Distribution of the pulmonary artery and vein of the orangutan lung

The distribution of the pulmonary artery and vein of the orangutan lung was examined. The right pulmonary artery runs obliquely across the ventral side of the right bronchus at the caudally to the right upper lobe bronchiole. It then runs across the dorsal side of the right middle lobe bronchiole. Thereafter it runs obliquely across the dorsal side of the right bronchus, and then along the dorso-medial side of the right bronchus. This course is different from that in other mammals. During its course, it gives off branches which run mainly along the dorsal or lateral side of each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole, then along the dorso-lateral side of the left bronchus, giving off branches which run along each bronchiole. The pulmonary veins run mainly the ventral or medial side of, along or between the bronchioles. In the left lung, the left middle lobe vein has two trunks; one enters the left atrium, and the other enters the left lower lobe pulmonary venous trunk. This is also different from that found in most mammals. Finally, the pulmonary veins enter the left atrium with four large veins.     

Measurement and Analysis of the Tracheobronchial Tree in Chinese Population Using Computed Tomography

Objective

To ascertain accurate measurements of, and the relationships between, the normative parameters of the tracheobronchial trees in the Chinese population using multi-slice spiral computed tomography (CT) and multi-planar reconstruction (MPR).

Materials and Methods

Measurements were performed on 2107 patients who underwent thoracic CT scans in the PLA General Hospital. The lengths of the trachea and the main stem bronchi, and the sizes of the subcarinal angle were obtained through CT or MPR imaging. Multi-variance analyses were performed to detect potential correlations between obtained parameters.

Results

The mean length of the trachea was 104.9 ± 13.4 mm (107.8 ± 13.2 mm for men and 101.4 ± 12.8 mm for women). The mean lengths of the right and left main stem bronchi were 13.6 ± 4.3 and 48.3 ± 6.5 mm, respectively. The right bronchus angle and the left bronchus angle were 34.9 and 42.5 degrees, respectively. Significant gender differences were found in all the parameters measured except for the angle of the right upper lobe bronchus. There are no statistically significant correlations among these parameters.

Conclusions

The normal reference values and the likely ranges of distribution of the tracheobronchial trees in the Chinese population have been established. Significant gender differences exist in the dimensions of the trachea, with the exception of the Right upper bronchial angle (RUA).