Unusual endobronchial extension of bronchial carcinoma treated by YAG laser and surgery.

A 54 year old man was admitted to our division as an emergency suffering from respiratory failure and haemoptysis. Chest radiographs and tomograms performed at another hospital showed collapse of the right lung (fig 1). The patient was given oxygen therapy and high dose steroid treatment (1 5 g of hydrocortisone daily) for 15 days. On his admission to hospital, blood gas analysis showed an arterial oxygen tension (Pao2) of 54 mm Hg (7-2 kPa), a carbon dioxide tension (Paco2) of 34 mm Hg (4.5 kPa), and pH 7 34. The respiratory rate was 36-40 breaths/minute. He was considered to be unable to perform spirometric tests and was excluded from surgical treatment because of his poor respiratory function and the extent of the tumour. An emergency fibreoptic bronchoscopy was performed and a polypoid intraluminal tumour completely obstructing the orifice of the right main bronchus was detected (histological examination later showed this to be a squamous cell carcinoma). At the same session, after informed consent by our patient, YAG laser phototherapy was carried out to give immediate relief from the obstruction. The fibre of the YAG laser was introduced through the operative channel of a fibreoptic bronchoscope (Olympus BFITIO) and treatment was begun with the patient still under local anaesthesia with 4% lignocaine. The first treatment lasted 50 minutes; 6570 joules were delivered in a 60 watt power setting in short pulses (lasting less than one second). As a result the mainstem bronchus and the right upper lobe bronchus were partially reopened. Immediately the patient's clinical condition improved and his respiratory distress diminished. The chest radiograph showed the partial reaeration of the lung; arterial oxygen and carbon dioxide tensions were 66 mm Hg and 42 mm Hg (8 8 and 5-6 kPa) respectively without further supplementary oxygen. Three more YAG laser treatments using the same tech-