[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]. / Leitlinie zur Langzeit-Sauerstofftherapie.

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

[Differential diagnosis and treatment of chronic cough]. / Differenzialdiagnose des chronischen Hustens. Behandeln Sie die Ursache, nicht das Symptom.

Postnasal drip, asthma and gastroesophageal reflux disease are the underlying causes in almost 90% of cases with chronic cough. Causal treatment is successful in the majority of patients, although in the event of a long-standing cough, it might need to be continued over several weeks. Smoking complicates the identification of cough as a clinical early symptom of an underlying tumor. Cardiac causes are rare, and in most cases are due to the use of ACE-inhibitors. Cough may be triggered by a variety of causes and the therapeutic palette must include several spectra. Since the individual causes often cannot be unequivocally identified, it may be necessary to take a polypragmatic therapeutic approach targeting the three most common causes simultaneously for 7-10 days.

Y-nitinol airway stent for management of central airway compression due to metastatic colon cancer.

Tumor masses in the area between the esophagus and the tracheobronchial tree can lead to complications involving both systems, mainly strictures and compressions. Malignant esophageal strictures are nowadays often treated by insertion of a metal stent which, however, can cause airway compression especially in the proximal area. We present here a new method of creating a Y-stent out of two self-expandable tracheal nitinol stents, utilizing fiber bronchoscopy, in a 55-year-old woman with advanced colon cancer metastastic to the mediastinum. The endo-Y-stent technique can be performed with the patient under sedation and having topical anesthesia. The opening through which the second tracheal stent must be placed for the Y construction is created by laser. In this case, the patient suffered from airway compression which was efficiently relieved by this method. Within a short time the endo-Y-stent provides effective restoration and maintenance of airway patency in patients with tumor compression in the region of the esophagus and airway, and in those with airway compression following esophageal stenting. Expertise in both stent implantation and laser application is, however, mandatory.

Interaction of bronchoalveolar lavage fluid with polyplexes and lipoplexes: analysing the role of proteins and glycoproteins.

BACKGROUND: Plasmid DNA complexed with cationic lipids (lipoplexes) or cationic polymers (polyplexes) has been used for gene transfer into the lung. Topical gene administration of lipoplexes or polyplexes into the lung after intratracheal instillation or aerosolisation could cause interaction of the complexes with extracellular substances of the airway surface liquid (ASL). These extracellular interactions might be causal for the observed inefficient transfection rate in vivo after topical administration. Therefore, we studied the impact of bronchoalveolar lavage fluid (BALF) on reporter gene expression mediated by non-viral gene vectors. BALF was considered as a model system to mimic possible interactions of the gene vectors with the ASL. METHODS: BALF was taken from 15 patients who underwent diagnostic bronchoscopy. Lipoplexes and polyplexes were incubated with increasing concentrations of BALF and major components of the BALF such as albumin, mucin and alpha(1)-glycoprotein, as a representative of glycosylated proteins. As cationic polymers, we tested dendrimers (fractured PAMAM) and polyethylenimine 25 kDa (PEI) and, as cationic liposomes, we used Lipofect-AMINE. The effect of BALF on polyplexes and lipoplexes was analysed by transfection experiments, fluorescence-quenching assay, 2-D-gel electrophoresis, SDS-PAGE, DNAse protection assay, size and zeta-potential measurements. RESULTS: BALF inhibited polyplex- and lipoplex-mediated gene transfer. Analysing components of BALF, we found that dendrimer-mediated gene transfer was not inhibited by any specific component. PEI-mediated gene transfer was dose-dependently inhibited by alpha(1)-glycoprotein, slightly inhibited by mucin, but not inhibited in the presence of albumin. Lipoplex-mediated gene transfer was inhibited by mucin at higher concentrations and by albumin, but not by alpha(1)-glycoprotein. 2-D-gel electrophoresis revealed that proteins of the BALF were adsorbed more intensively to lipoplexes than to polyplexes. In addition, mucin and alpha(1)-glycoprotein also adsorbed more intensively to lipoplexes than to polyplexes. Adsorption of BALF components led to a decrease in the positive zeta-potential of lipoplexes and led to a negative zeta-potential of polyplexes. Complement cleavage fragment C3 beta, and in the case of lipoplexes also the C3 alpha fragment, were found among the proteins opsonised on gene vectors. CONCLUSIONS: Our study shows that BALF contains inhibitory components for non-viral gene transfer. We could not detect a specific inhibitory component, but inhibition was most likely due to the change in the surface charge of the gene vectors. Interestingly, there is evidence for complement activation when the route of pulmonary gene vector administration is chosen. Consequently, shielding of gene vectors to circumvent interaction with the ASL environment should be a focus for pulmonary administration in the future.

All trans-retinoic acid selectively down-regulates matrix metalloproteinase-9 (MMP-9) and up-regulates tissue inhibitor of metalloproteinase-1 (TIMP-1) in human bronchoalveolar lavage cells.

BACKGROUND: The balance between proteinases and antiproteinases plays an important role in tissue destruction and remodelling. In chronic obstructive pulmonary disease (COPD) and emphysema, an imbalance between matrix metalloproteinases (MMPs) and inhibitors of tissue metalloproteinase (TIMPs) has been reported. Alveolar macrophages are considered to be the main source of MMPs. We therefore have analyzed the effects of free and liposomal all trans-retinoic acid (ATRA) on the expression of MMP-9 and TIMP-1 in bronchoalveolar lavage (BAL) cells from patients with COPD and patients with other lung diseases. MATERIAL AND METHODS: BAL cells were incubated 1-3 day with either liposomal or free ATRA. Supernatants were tested for MMP-9 and TIMP-1 protein in specific ELISA systems; mRNA analysis was performed by semi-quantitative RT-PCR and by quantitative LightCycler PCR. RESULTS: We demonstrate that either liposomal or free ATRA selectively down-regulates MMP-9 and up-regulates TIMP-1. At the protein level, MMP-9 is decreased 3-fold and TIMP-1 is increased 3.5-fold compared to the base line with empty liposomes or untreated cells. The ratio of MMP-9 and its inhibitor TIMP-1, which may be crucial to the overall proteolytic potential decreased by factor 8. That this countercurrent effect of ATRA is not due to an altered protein stability but to transcriptional regulation could be demonstrated by RT-PCR. Quantitative LightCycler analysis revealed a 2.5-fold decrease of MMP-9 mRNA and a 4.5 fold increase of TIMP- 1 mRNA. CONCLUSIONS: These data suggest that ATRA treatment via its impact on the proteinase/antiproteinase ratio may become a new therapeutic strategy for patients with inflammatory destructive lung diseases.

[Bronchoscopy in Germany. Cross-sectional inquiry with 681 institutions]. / Bronchoskopie in Deutschland: Querschnitterhebung an 681 Institutionen.

Bronchoscopy represents an integral part of the diagnostic tools in pulmonary medicine. Recently, it has also gained considerable attention for its therapeutic properties. To elucidate equipment, indications and procedural techniques of bronchoscopy units, a retrospective survey of 1232 hospitals and practices is conducted. 687 questionnaires are received back (response rate 56%). 681 of which are statistically evaluated. Two thirds of the physicians in charge are internists, one third are pulmonary care specialists. A total of 200,596 endoscopic procedures is included. The majority of procedures is done with an average of 3 bronchoscopists and in over 57% (388) of cases with an average number of 100 or less procedures per year. The five main indications are tumor, hemoptysis, infection or pneumonia, drainage of secretions and suspected interstitial disease. Overall complication rate amounts to 2.7% with an incidence of 4.6% minor and 0.7% major complications and a bronchoscopy-related mortality of 0.02%. The patterns seen in premedication, intra- and post-procedural monitoring, disinfection practices as well as documentation are quite heterogeneous. It is suggested to establish revised and updated standards for bronchoscopy, which should take the data collected into particular account. Those standards should provide the basis for a high level bronchological care throughout Germany.

alpha-Thrombin stimulates contraction of human bronchial rings by activation of protease-activated receptors.

In a variety of diseases, inflammation causes microvascular leakage and activates thrombin. Evidence suggests that thrombin increases cytosolic calcium and stimulates human airway smooth muscle (ASM) cell proliferation. The receptor subtypes, however, that mediate the effects of thrombin on ASM cell growth or calcium mobilization remain unknown. In this study, we postulate that thrombin, which activates specific protease-activated receptors (PARs), also stimulates contraction of isolated human bronchial rings. With the use of intact human bronchial rings, alpha-thrombin (1-20 U/ml) increased bronchial tone to 19 +/- 3% of basal tone (P = 0.008; n = 5 experiments) and represents 20 +/- 8% of the maximum carbachol response. The EC(50) for thrombin-induced force generation was 12.2 U/ml (95% confidence interval 9.9-15.3 U/ml) and was not altered in bronchial rings that had the epithelium removed. In parallel experiments, a specific thrombin receptor-activating peptide (TRAP-14; 0.1-100 micromol/l) increased isometric tension to levels (14 +/- 2%; P = 0.0005; n = 5 experiments) comparable to those rings stimulated with thrombin. To characterize the receptors that mediate thrombin effects on human ASM, the expression of PARs in cultured human ASM cells was analyzed by RT-PCR analysis with specific primers for PARs. In these cells, PAR1 (thrombin receptor), PAR2, and PAR3 were expressed at comparable levels. In other experiments using immunocytochemical staining with specific antibodies to PAR1 and PAR2, we showed that ASM in bronchial rings and cultured ASM cells express PAR1 and PAR2 proteins. Taken together, these studies suggest that alpha-thrombin, in a receptor-specific and dose-dependent manner, induces contraction of bronchial rings in vitro. In addition, cultured human ASM cells express mRNA of PAR1, PAR2, and PAR3 and express PAR1 and PAR2 protein. Further studies are needed to determine whether alpha-thrombin plays a role in stimulating bronchoconstriction in inflammatory airway diseases such as asthma and bronchiolitis obliterans.

[Flexible bronchoscopic implantation of Accuflex and Strecker stents in malignant bronchial stenoses]. / Flexible bronchoskopische Implantation von Accuflex und Strecker Stents bei malignen Bronchialstenosen.

Silicone and metal stents are available for the treatment of malignant bronchial stenoses. This project sought to compare the self-expanding nitinol Accuflex stent (Boston Scientific Corp; Watertown, Mass) with the passively expandable tantalum Strecker stent (Boston Scientific Corp; Watertown, Mass), both implanted by flexible bronchoscopy under local anesthesia and sedation. In 51 patients with malignant bronchial stenosis, 14 nitinol and 51 tantalum stents were used and stenoses of 75 to 100% were treated. The intervention was successful in all but one patient, a mean patency of 93% was achieved. In the follow-up period, the probability of survival was significantly lower in patients with total bronchus occlusion than in patients with stenotic alteration (44 vs 109 days; p < 0.05). In 10 patients, lung function analysis after stent implantation revealed a significant increase in PaO2 (65 vs 71 mm Hg; p < 0.01), inspiratory vital capacity (2.5 vs 2.7 L; p < 0.05), and FEV1 (1.8 vs 2.0 L; p < 0.05). Mucus retention was the main (39%) adverse factor in the early phase after stent implantation, whereas tumor penetration became the most frequent problem (67%) in the later phase. Recanalizing interventions were necessary in 18% of the cases in which tumor penetration occurred. Stent distortion occurred in 12 patients with Strecker and in none with Accuflex stents. In comparison to the Strecker stent, the self-expanding Accuflex stent is preferable owing to its excellent flexibility and faster delivery system. Both types of stents could be sufficiently deployed within the lesions and allowed for highly precise positioning. Furthermore, no general anesthesia was required. The fiber-bronchoscopy mode of implantation under sedation is very efficient even for tumor patients with severe impairment of their physical and respiratory condition.

Preoperative bronchoscopic assessment of airway invasion by esophageal cancer: a prospective study.

BACKGROUND: Bronchoscopy is frequently used to assess invasion of esophageal cancer into the tracheobronchial tree. Prospective studies evaluating the role of bronchoscopy in pretherapeutic staging of esophageal cancer are lacking. STUDY OBJECTIVES: To evaluate the diagnostic utility of fiberoptic bronchoscopy for the assessment of airway involvement by esophageal carcinoma and its resectability. PATIENTS AND METHODS: In a prospective study, we analyzed 150 bronchoscopies in 116 consecutive patients with potentially operable esophageal carcinoma, and correlated the findings with other staging modalities, intraoperative evaluation, and histopathologic data. RESULTS: One unknown additional bronchial cancer was found. In 32% of bronchoscopies performed in patients with esophageal cancer located above the tracheal bifurcation, some macroscopic abnormality was detected in the trachea and main bronchi, with mobile protrusion of the posterior tracheal wall being the most frequent abnormality (20.7%). When compared with histologic results, normal macroscopic appearance of the trachea and main bronchi had a negative predictive value of 98.5%, but the positive predictive value of all macroscopic abnormalities for the diagnosis of airway involvement was low, particularly after radiation therapy. The overall accuracy of bronchoscopy with multiple brush cytology and biopsy sampling in proving or excluding airway invasion in patients with otherwise operable conditions was 95.8% (95% confidence interval, 88.3 to 99.1%). Bronchoscopy was the sole decisive staging procedure, resulting in exclusion from surgery because of airway invasion, in 9.7% of patients with otherwise potentially operable conditions. The results of bronchoscopy and CT were discordant in 40% of the patients; the specificity and positive predictive value were higher for bronchoscopy than for CT. CONCLUSIONS: When performed as the last investigation in the staging workup, bronchoscopy with biopsy and brush cytology is a very accurate procedure in evaluating possible airway invasion of esophageal cancer; macroscopic findings alone are not reliable.

Ventilation perfusion scintigraphy and lung function testing to assess metal stent efficacy.

UNLABELLED: Stent implantation in malignant bronchial stenoses is a highly effective method of providing symptomatic relief by restoring bronchial patency. Whether an improvement in ventilatory conditions is paralleled by an increase in blood flow and gas exchange has not yet been determined. METHODS: Fourteen patients with malignant, high-grade obstruction of bronchi who had metal stent implantation were investigated. Before the intervention and again 8 days afterward, both quantitative technegas ventilation and 99mTc-MAA perfusion scans (V/Q scans) and lung function tests were performed. RESULTS: Stent implantation was successful in all patients, with a significant reduction in the degree of bronchial stenosis (pre-stent: 93% +/- 1.5%; post-stent: 16% +/- 3.5%). After stent implantation, ventilation scintigraphy revealed an improvement in tracer deposition by 65% (pre-stent: 37% +/- 8%; post-stent: 61% +/- 6%; p < 0.05) within the affected lung. A complementary increase of 71% by perfusion scintigraphy was obtained (pre-stent: 27% +/- 4%; post-stent: 46% +/- 5%; p < 0.01%). Based on scintigraphic criteria, stenting was successful in 93% (n = 13) of all patients. Lung function studies performed after the intervention showed significant improvement in vital capacity (VC, p < 0.01), forced expiratory volume in 1 sec (FEV1, p < 0.05), peak expiratory flow (PEF, p < 0.05), arterial oxygen (PaO2, p < 0.05) and carbon dioxide (PaCO2, p < 0.05) tension, and oxygen saturation (p < 0.05). CONCLUSION: Stenting of malignant high-grade bronchial obstructions leads to an increase in bronchial patency and in activity distribution of both ventilation and perfusion scintigraphy of the affected lung, accompanied by significant improvement in lung function parameters.

Effects of beta 2-agonist- and dexamethasone-treatment on relaxation and regulation of beta-adrenoceptors in human bronchi and lung tissue.

1. Long-term treatment with beta 2-adrenoceptor agonists can lead to a decreased therapeutic efficacy of bronchodilatation in patients with obstructive pulmonary disease. In order to examine whether or not this is due to beta-adrenoceptor desensitization, human bronchial muscle relaxation was studied in isolated bronchial rings after pretreatment with beta 2-adrenoceptor agonists. Additionally, the influence of pretreatment with dexamethasone on desensitization was studied. 2. The effect of beta 2-agonist incubation alone and after coincubation with dexamethasone on density and affinity of beta-adrenoceptors was investigated by radioligand binding experiments. 3. In human isolated bronchi, isoprenaline induces a time- and concentration-dependent beta-adrenoceptor desensitization as judged from maximal reduction in potency by a factor of 7 and reduction of 73 +/- 4% in efficacy of isoprenaline to relax human bronchial smooth muscle. 4. After an incubation period of 60 min with 100 mumol l-1 terbutaline, a significant decline in its relaxing efficacy (81 +/- 8%) and potency (by a factor 5.5) occurred. 5. Incubation with 30 mumol l-1 isoprenaline for 60 min did not impair the maximal effect of a subsequent aminophylline response but led to an increase in potency (factor 4.4). 6. Coincubation of dexamethasone with isoprenaline (120 min; 30 mumol l-1) preserved the effect of isoprenaline on relaxation (129 +/- 15%). 7. In radioligand binding experiments, pretreatment of lung tissue for 60 min with isoprenaline (30 mumol l-1) resulted in a decrease in beta-adrenoceptor binding sites (Bmax) to 64 +/- 1.6% (P < 0.05), while the antagonist affinity (KD) for [3H]-CGP-12177 remained unchanged. 8. In contrast, radioligand binding studies on lung tissue pretreated with either dexamethasone (30 mumol l-1) or isoprenaline (30 mumol l-1) plus dexamethasone (30 mumol l-1) for 120 min did not lead to a significant change of Bmax (160 +/- 22.1% vs 142.3 +/- 28.7%) or KD (5.0 nmol l-1 vs 3.5 nmol l-1) compared to the controls. 9. In conclusion, pretreatment of human bronchi with beta-adrenoceptor agonists leads to functional desensitization and, in lung tissue, to down-regulation of beta-adrenoceptors. This effect can be counteracted by additional administration of dexamethasone. Our model of desensitization has proved useful for the identification of mechanisms of beta-adrenoceptor desensitization and could be relevant for the evaluation of therapeutic strategies to counteract undesirable effects of long-term beta-adrenoceptor stimulation.

Implantation of Accuflex and Strecker stents in malignant bronchial stenoses by flexible bronchoscopy.

Silicone and metal stents are available for the treatment of malignant bronchial stenoses. This project sought to compare the self-expanding nitinol Accuflex stent (Boston Scientific Corp; Watertown, Mass) with the passively expandable tantalum Strecker stent (Boston Scientific Corp; Watertown, Mass), both implanted by flexible bronchoscopy under local anesthesia and sedation. In 51 patients with malignant bronchial stenosis, 14 nitinol and 51 tantalum stents were used and stenoses of 75 to 100% were treated. The intervention was successful in all but one patient; a mean patency of 93% was achieved. In the follow-up period, the probability of survival was significantly lower in patients with total bronchus occlusion than in patients with stenotic alterations (44 vs 109 days; p<0.05). In 10 patients, lung function analysis after stent implantation revealed a significant increase in PaO2 (65 vs 71 mm Hg; p<0.01), inspiratory vital capacity (2.5 vs 2.7 L; p<0.05), and FEV1 (1.8 vs 2.0 L; p<0.05). Mucus retention was the main (39%) adverse factor in the early phase after stent implantation, whereas tumor penetration became the most frequent problem (67%) in the later phase. Recanalizing interventions were necessary in 18% of the cases in which tumor penetration occurred. Stent distortion occurred in 12 patients with Strecker and in none with Accuflex stents. In comparison to the Strecker stent, the self-expanding Accuflex stent is preferable owing to its excellent flexibility and faster delivery system. Both types of stents could be sufficiently deployed within the lesion and allowed for highly precise positioning. Furthermore, no general anesthesia was required. The fiberbronchoscopic mode of implantation under sedation is very efficient even for tumor patients with severe impairment of their physical and respiratory condition.

Atrial natriuretic peptide in acute hypoxia-exposed healthy subjects and in hypoxaemic patients.

Plasma atrial natriuretic peptide (ANP) is an endogenous vasodilator, which might counteract pulmonary hypertension due to hypoxaemia. The aim of this study was to investigate the influence of acute and chronic hypoxia on plasma (ANP) concentrations in humans. Venous plasma ANP concentrations in six healthy subjects were measured before and after inhalation of hypoxic air (11% O2) at rest for 30 min, and following 5 min of mild hypoxic exercise (25 W). Pulmonary arterial plasma ANP levels were determined in 31 right heart catheterized patients with lung disease. In healthy subjects, mean arterial oxygen tension (Pao2) was 6.8 +/- 1.9 kPa after 30 min hypoxia at rest, and 4.7 +/- 0.9 kPa after hypoxic exercise testing. Hypoxia at rest did not induce significant changes in ANP concentrations, whereas hypoxic exercise led to significantly increased ANP levels. Among hypoxaemic patients, significantly elevated plasma ANP levels were found only in the subgroup with increased mean pulmonary artery pressure, but not in the subgroup with normal pulmonary artery pressure. In summary, severe acute hypoxia induced by hypoxic exercise, but not moderate acute hypoxia at rest, leads to increased ANP levels in healthy subjects. Chronic hypoxia alone does not lead to elevated plasma ANP levels; whereas, hypoxia combined with pulmonary hypertension causes increased plasma ANP concentrations in diseased subjects.

Combined amyloidosis of the upper and lower respiratory tract.

Pulmonary and laryngeal manifestations of localized and organ-limited amyloidosis are sometimes seen, although pulmonary and laryngeotracheal amyloidosis are not always associated. Diagnosis can only be established histologically by the characteristic green birefringence in polarized light after Congo red staining and by immunohistochemical techniques. We describe the case of a 77-year-old woman who presented with hoarseness and an unproductive cough due to extensive amyloid deposits in both the upper and lower respiratory tract, immunohistochemically proven as the A lambda-type.

Pharmacological actions of the selective and non-selective beta-adrenoceptor antagonists celiprolol, bisoprolol and propranolol on human bronchi.

1. The pharmacological actions of the beta-adrenoceptor antagonists, celiprolol, bisoprolol and propranolol were investigated in human lung tissue by radioligand binding experiments as well as in human isolated bronchi by functional experiments in organ baths. 2. Data from lung tissue were compared to those obtained from myocardial membranes. 3. Lung tissue was obtained from 10 patients having undergone lung resection for bronchial carcinoma and myocardial tissue from a patient who had received a heart transplantation. 4. In radioligand binding experiments, celiprolol exhibited a high affinity binding to beta 1-adrenoceptors in heart and a low affinity binding to beta 2-adrenoceptors in lung tissue. The selectivity obtained for the beta 1-adrenoceptor was calculated to a factor of eleven. 5. Compared to bisoprolol and propranolol, celiprolol elicited the lowest affinity for the beta-adrenoceptor, as judged from the K1-values. 6. In the absence and presence of the guanine nucleotide Gpp(NH)p celiprolol did not affect receptor binding. 7. In functional experiments on intact bronchi, celiprolol, bisoprolol and propranolol failed to produce relaxation (+/- forskolin) or a significant difference in efficacy in antagonizing the relaxant effects of isoprenaline. However, a rank order of potencies was revealed (propranolol:bisoprolol:celiprolol = 46:12:1). 8. Plasma concentrations for celiprolol and bisoprolol usually achieved in vivo were below the IC50 value obtained in vitro. In contrast, for propranolol, plasma concentrations were nearly identical with the IC50 value. 9. It is concluded that celiprolol is a selective beta 1-adrenoceptor antagonist on human heart and has no agonistic properties on intact human bronchi. Compounds such as celiprolol and bisoprolol may in comparison to propranolol, possess reasonable therapeutic advantages in the treatment of patients with obstructive lung disease due to their low affinity for beta 2-adrenoceptors.

Bronchoscopy of lung cancer.

Lung cancer is a leading cancer site in men and women with a high incidence and mortality rate. Most patients are diagnosed when the disease has already spread. An early, detection and immediate and accurate histological or cytological diagnosis are essential for a hopeful outcome. In most patients, bronchoscopy is the method of choice in establishing a suspected lung neoplasm. With the rigid and flexible method, two complementary techniques are available. The methods bear a very low mortality rate if sufficient monitoring and resuscitative instrumentation is available. Rigid bronchoscopy offers the possibility of obtaining large biopsy specimens from the tumorous tissue and provides an effective tool in the control of major haemorrhage. However, it cannot be used for the inspection of further peripherally located parts of the bronchial system and needs general anaesthesia. In contrast, the flexible method can be quickly and readily performed at practically any location using portable equipment. Bronchi can be inspected up to the 8th order and with bronchial washing, forceps biopsy, brush biopsy and fluorescence bronchoscopy techniques with a high diagnostic yield are available. This holds true, especially if these sampling techniques are used as complementary methods.