Assessment of an ultrathin bronchoscope that allows cytodiagnosis of small airways

Diagnostic value of ultrathin bronchoscopy in peripheral pulmonary lesions: a narrative review

Flexible bronchoscopes are being continuously improved, and an ultrathin bronchoscope with a working channel that allows the use of a radial-type endobronchial ultrasound (EBUS) probe is now available. The ultrathin bronchoscope has good maneuverability for passing through the small bronchi and good accessibility to peripheral lung lesions. This utility is particularly enhanced when it is used with other imaging devices, such as EBUS and navigation devices. Multimodality bronchoscopy using an ultrathin bronchoscope leads to enhanced diagnostic yield.

Technologies for targeting the peripheral pulmonary nodule including robotics

Bronchoscopic sampling of PPL was significantly advanced by the development of the endobronchial ultrasound guide sheath method in the 1990s. Since then, a range of technical and procedural techniques have further advanced diagnostic yields. These include the use of thinner bronchoscopes with better working channel diameters, understanding the importance of peripheral transbronchial needle aspiration, and virtual bronchoscopic assistance. These have enabled better sampling of smaller and more technically challenging lesions including ground-glass nodules. Most recently, robotic bronchoscopy has been developed which, among other refinements, allows fine control of visual bronchoscopic navigation by replacing movements directed by the hand with electronic consoles and trackballs, and innovatively integrate virtual with real bronchoscopic pathways. The requirement for PPL diagnosis and treatment is expected to increase with more chest CT performed as part of CT screening programmes.

Probe-based optical fiberscopy for the direct observation of peripheral pulmonary lesions

BACKGROUND

Peripheral pulmonary lesions are rarely observed directly before transbronchial biopsy. This study aimed to characterize the differences between malignant and benign peripheral pulmonary lesions according to the findings of direct observation using probe-based optical fiberscopy.

METHODS

Thirty patients who underwent probe-based optical fiberscopy in combination with bronchoscopy using endobronchial ultrasonography with a guide sheath for the evaluation of peripheral pulmonary lesions were prospectively included in this study. The patients were divided into the malignant and benign groups according to their final diagnosis. The findings of probe-based optical fiberscopy in the two groups were compared.

RESULTS

The numbers of patients who were diagnosed using histological or bacteriological analyses via bronchoscopic sampling in the malignant and benign groups were 20/23 (87.0%) and 2/7 (28.6%), respectively. On probe-based optical fiberscopy, angiogenesis and vascular engorgement were observed only in the malignant group. The disappearance of subepithelial microvessel transparency and presence of bronchiolar stenosis were observed more frequently in the malignant group (78.3% and 60.9%) than in the benign group (28.6% and 28.6%), whereas increased mucus secretion was observed more frequently in the benign group (71.4%) than in the malignant group (8.7%).

CONCLUSIONS

These results suggest that the findings of direct observation using probe-based optical fiberscopy are useful for differentiating malignant from benign peripheral pulmonary lesions.

TRIAL REGISTRY

UMIN-CTR; UMIN000018796; URL: https://www.umin.ac.jp/ctr/index.htm.

Multidetector CT and postprocessing in planning and assisting in minimally invasive bronchoscopic airway interventions

A widening spectrum of increasingly advanced bronchoscopic techniques is available for the diagnosis and treatment of various bronchopulmonary diseases. The evolution of computed tomography (CT)-multidetector CT in particular-has paralleled these advances. The resulting development of two-dimensional and three-dimensional (3D) postprocessing techniques has complemented axial CT interpretation in providing more anatomically familiar information to the pulmonologist. Two-dimensional techniques such as multiplanar recontructions and 3D techniques such as virtual bronchoscopy can provide accurate guidance for increasing yield in transbronchial needle aspiration and transbronchial biopsy of mediastinal and hilar lymph nodes. Sampling of lesions located deeper within the lung periphery via bronchoscopic pathways determined at virtual bronchoscopy are also increasingly feasible. CT fluoroscopy for real-time image-guided sampling is now widely available; electromagnetic navigation guidance is being used in select centers but is currently more costly. Minimally invasive bronchoscopic techniques for restoring airway patency in obstruction caused by both benign and malignant conditions include mechanical strategies such as airway stent insertion and ablative techniques such as electrocauterization and cryotherapy. Multidetector CT postprocessing techniques provide valuable information for planning and surveillance of these treatment methods. In particular, they optimize the evaluation of dynamic obstructive conditions such as tracheobronchomalacia, especially with the greater craniocaudal coverage now provided by wide-area detectors. Multidetector CT also provides planning information for bronchoscopic treatment of bronchopleural fistulas and bronchoscopic lung volume reduction for carefully selected patients with refractory emphysema.

CT-guided ultrathin bronchoscopy: bioptic approach and factors in predicting diagnosis

BACKGROUND

The diagnostic sensitivity of current bronchoscopy for peripheral lung cancer is inadequate because the bronchoscope insertion range is limited and confirmation of the position of the biopsy apparatus at the lesion under X-ray fluoroscopy is inaccurate. The combination of ultrathin bronchoscopy and computed tomography (CT) is effective for solving these problems.

OBJECTIVE

This study was a retrospective study analyzing prospectively collected data to identify factors contributing to the diagnosis and the appropriate biopsy method in CT-guided ultrathin bronchoscopy for peripheral lung cancer.

METHODS

The subjects comprised 86 patients (88 lesions) who underwent CT-guided ultrathin bronchoscopy and were finally diagnosed with peripheral lung cancer. We evaluated the diagnostic yield according to specific factors and also according to the sample collection method.

RESULTS

Sixty-nine lesions were diagnosed as lung cancer, and the diagnostic yield was 78.4% (80.3% in lesions ≤2 cm in diameter). Multivariate analysis showed that the factors contributing to the diagnosis were the observation range by ultrathin bronchoscopy and the presence/absence of the involved bronchus or pulmonary artery. Pathological evaluation facilitated histological diagnoses in 53 (65.4%) of 81 lesions. In 16 lesions, only the cytological diagnosis was positive.

CONCLUSION

CT-guided ultrathin bronchoscopy may be particularly useful for lesions for which the involved bronchus or pulmonary artery can be confirmed, and observation of bronchi of the 6th generation or more is possible. Since the specimen preparation rate is low, the combination of histopathological diagnosis with cytological diagnosis particularly that of the discharge attached to the forceps, is optimal.

Successful establishment of primary small airway cell cultures in human lung transplantation

Background

The study of small airway diseases such as post-transplant bronchiolitis obliterans syndrome (BOS) is hampered by the difficulty in assessing peripheral airway function either physiologically or directly. Our aims were to develop robust methods for sampling small airway epithelial cells (SAEC) and to establish submerged SAEC cultures for downstream experimentation.

Methods

SAEC were obtained at 62 post-transplant bronchoscopies in 26 patients using radiologically guided bronchial brushings. Submerged cell cultures were established and SAEC lineage was confirmed using expression of clara cell secretory protein (CCSP).

Results

The cell yield for SAEC (0.956 ± 0.063 × 10⁶) was lower than for large airway cells (1.306 ± 0.077 × 10⁶) but did not significantly impact on the culture establishment rate (79.0 ± 5.2% vs. 83.8 ± 4.7% p = 0.49). The presence of BOS significantly compromised culture success (independent of cell yield) for SAEC (odds ratio (95%CI) 0.067 (0.01-0.40)) but not LAEC (0.3 (0.05-1.9)). Established cultures were successfully passaged and expanded.

Conclusion

Primary SAEC can be successfully obtained from human lung transplant recipients and maintained in culture for downstream experimentation. This technique will facilitate the development of primary in vitro models for BOS and other diseases with a small airway component such as asthma, cystic fibrosis and COPD.

Usefulness of ultrathin bronchoscopy in diagnosis of lung cancer

Although ultrathin bronchoscopes are suggested to have comparable abilities to conventional bronchoscopes in diagnosing peripheral lung lesions, how to introduce ultrathin bronchoscopes into bronchoscopic examination is still to be determined. In our first study, 35 patients with peripheral lung lesions underwent ultrathin followed by conventional bronchoscopy to compare their diagnostic abilities. The diagnostic rate was 54.3% in conventional bronchoscopy alone, 60.0% in ultrathin bronchoscopy alone, and 62.8% in the combination of the two. In the next study, we introduced a rapid cytology test of the material obtained in conventional bronchoscopy. When malignant cells were not detected in the material by the rapid cytology, ultrathin bronchoscopy was immediately conducted. Thirty-two patients with negative rapid cytology were enrolled in this study. Ultrathin bronchoscopy resulted in diagnostic materials in 59.3% of these cases. Ultrathin bronchoscopes showed better access to the lesions than a brush or a curette introduced through conventional bronchoscopes. We conclude that ultrathin bronchoscopes have a comparable ability to conventional ones in diagnosing peripheral lung cancer even when used alone, and become a good complement to conventional ones by introducing the rapid cytology test.

Use of an ultrathin bronchoscope in the assessment of central airway obstruction

STUDY OBJECTIVE

To assess the utility of an ultrathin bronchoscope (UB) in the assessment of central airway obstruction (CAO).

DESIGN

Prospective evaluation

SETTING

Tygerberg Hospital, a tertiary teaching hospital.

PATIENTS

Consecutive patients referred to the Lung Unit with CAO.

INTERVENTIONS

Fiberoptic bronchoscopy (FOB) was performed with a prototype UB (Olympus BF XP40; Olympus Europe; Hamburg, Germany; outer diameter, 2.8 mm; working channel, 1.2 mm). The UB was used whenever a standard bronchoscope (SB) could not pass the obstruction or could not be tolerated by the patient.

MEASUREMENTS AND RESULTS

Data relating to indication and performance of FOB, patient demographics, utility in establishing a diagnosis, and planning definitive management were documented. Twenty-four patients (17 men; mean age, 46 years) were studied. Twelve patients (50%) had malignant CAO, 8 patients (33%) had benign tracheal stenosis, 3 patients (12.5%) had stent occlusion, and 1 patient (4%) had bilateral vocal cord paralysis. In 42% of patients, an initial attempt at passing the obstruction with an SB had failed. Vocal cords or trachea were involved in 62% of patients. The mean luminal occlusion was 84% of the total airway lumen (range, 50 to 100%). One complication (desaturation) led to early termination of FOB. In all but three patients with complete obstruction, the UB was able to pass the CAO and allowed assessment of the obstruction and the distal airways (87%).

CONCLUSION

UB-FOB was useful and safe in the assessment of patients with CAO from both benign and malignant disease. It aided in establishing a diagnosis and/or planning of definitive management in all patients examined.

Diesel exhaust particles upregulate eotaxin gene expression in human bronchial epithelial cells via nuclear factor-kappa B-dependent pathway

Fine particles derived from diesel engines, diesel exhaust particles (DEP), have been shown to augment gene expression of several inflammatory cytokines in human airway epithelial cells in vitro. However, it remains unclear whether or not DEP have any effect on the expression and production of eotaxin, an important chemokine involved in eosinophil recruitment into the airways. We studied the effects of DEP by using a conventional suspended DEP and by a recently established in vitro cell exposure system to diesel exhaust (Abe S, Takizawa H, Sugawara I, and Kudoh S, Am J Respir Cell Mol Biol 22: 296-303, 2000). DEP showed a dose-dependent stimulatory effect on eotaxin production by normal human peripheral airway epithelial cells as well as by bronchial epithelial cell line BET-1A as assessed by specific ELISA. mRNA levels increased by DEP were shown by RT-PCR. DEP showed an additive effect on IL-13-stimulated eotaxin expression. DEP induced NF-kappaB activation by EMSA as previously reported but did not induce signal transducer and activator of transcription (STAT) 6 activation according to Western blot analysis. Finally, antioxidant agents (N-acetyl cysteine and pyrrolidine dithiocarbamate), which inhibited NF-kappaB activation but failed to affect STAT6 activation, almost completely attenuated DEP-induced eotaxin production, whereas these agents failed to attenuate IL-13-induced eotaxin production. These findings suggested that DEP stimulated eotaxin gene expression via NF-kappaB-dependent, but STAT6-independent, pathways.

Management of solitary pulmonary nodules: how do thoracic computed tomography and guided fine needle biopsy influence clinical decisions?

BACKGROUND

Computed tomography (CT) and fine needle guided biopsy (FNB) are often used in the assessment of patients with lung nodules. The influence of these techniques on clinical decision making has not been quantified, especially for small solitary pulmonary nodules (SPN) where the probability of malignancy is lower. A study was undertaken to determine the effect of CT and FNB derived information on clinical decision making in patients with a solitary pulmonary nodule < or = 3 cm in diameter on initial chest radiography.

METHODS

Clinical, physiological, and outcome data on 114 patients with an SPN < or = 3 cm who had subsequent thoracic CT and FNB were extracted from the records of a specialist cardiorespiratory hospital in Auckland, New Zealand. Chest radiographs and CT scans were reported according to specified criteria by a thoracic radiologist. Computer generated summary sheets were used to present cases to each of six clinicians. Each case was presented three times: (1) with clinical data and chest radiograph only; (2) with the addition of the CT report; and (3) with all data including the result of the FNB. Clinicians were asked to specify their management on each occasion and to estimate the probability of the lesion being malignant. Reproducibility was assessed by re-evaluating 24 cases 1 month later.

RESULTS

33 (29%) nodules were benign, 35 (31%) nodules (malignant) were resected with negative node sampling, and 46 (40%) had a non-curative outcome (radiotherapy, incomplete resection, refused therapy). Intra-clinician decision making was consistent for all three levels of clinical data (median kappa values 0.79-0.89). Agreement between clinicians on the need for surgery was lowest with chest radiography alone (kappa=0.33), rose with CT information (kappa=0.44), and increased further with the addition of the FNB data (kappa=0.57). The proportion of successful decisions on surgical intervention (against the known outcome) increased with the addition of CT reports and further with FNB reports (p=0.006, Friedman's test). The major benefit of the information added by CT and FNB reports was a reduction in unnecessary surgery, especially when the clinical perception of pre-test probability of malignancy was intermediate (31-70%). FNB data contributed most to the benefit (p<0.001). The addition of CT and FNB was cost efficient and can be applied specifically to patients with a low or intermediate probability of malignancy.

CONCLUSION

Both CT and FNB make cost effective contributions to the clinical management of SPN < or = 3 cm in diameter by reducing unnecessary operations and increasing agreement between physicians on the need for surgery.

Interferon-gamma inhibits hepatocyte growth factor-stimulated cell proliferation of human bronchial epithelial cells: upregulation of p27(kip1) cyclin-dependent kinase inhibitor

Proliferation of bronchial epithelial cells is an important biologic process in a variety of physiologic and pathologic conditions. In this study, we demonstrate that hepatocyte growth factor (HGF) stimulates proliferation of human bronchial epithelial cells obtained from healthy volunteers. The mitogenic effect of HGF is dependent on costimulation with serum and is completely abrogated by interferon-gamma (IFN-gamma). In the absence of serum, HGF is capable of inducing activation of extracellular signal-regulated kinases (ERK)1 and ERK2, but fails to stimulate proliferation by itself. These effects of HGF and IFN-gamma were reproduced faithfully in BEAS-2B cells, which are an immortalized cell line derived from human bronchial epithelial cells. Further, we investigated the molecular mechanisms underlying the effects of HGF and IFN-gamma in BEAS-2B cells and found that the MEK1 inhibitor PD98059, but not the p38 M-associated protein kinase inhibitor SB203580, abrogates HGF-induced ERK activation and proliferation in response to HGF and serum. In addition, LY294002, which is the specific inhibitor of phosphatidyl inositol 3-kinase, partially inhibited HGF- and serum-stimulated proliferation. We also found that HGF by itself is capable of inducing a G1 cyclin, cyclin D1, but fails to downregulate p27(kip1) cyclin-dependent kinase (CDK) inhibitor, which is a requisite for G1 to S phase cell cycle progression. IFN-gamma does not interfere with the effects of HGF on either ERK activation or cyclin D1 induction; however, it prevents the downregulation of p27(kip1) CDK inhibitor that takes place in response to a combination of HGF and serum. These results indicate that the MEK-ERK signaling pathway is necessary but not sufficient for human bronchial epithelial cell proliferation, and implicate the significance of HGF and IFN-gamma in the repair processes of injured human bronchial epithelial cells.

Fluorescence bronchoscopy for early detection of lung cancer: a clinical perspective

The conventional method of bronchoscopy has only a 30% sensitivity to detect early stage cancer in the central airways. For patients with positive sputum cytology who clearly harbor early cancers, repeat and lengthy sessions of bronchoscopies are required for accurate localization of these lesions. This leads to a significant delay in obtaining the diagnosis, postponing an appropriate treatment and reduces the chance for cure. There are valid reasons for improving the detection rate of early stage lung cancers. The number of individuals at risk forms a large population, the outcome of patients treated with early stage cancer has been shown to be better and bronchoscopic treatments, e.g. photodynamic therapy and electrocautery, are currently alternatives for surgical resection. Finding more early stage cancers by screening the population at risk and accurate staging to enable treatment at the earliest stage feasible, may improve the dismal prognosis of many patients. This article deals with the clinical background and current problems in early detection of lung cancer and discusses our expectations regarding new developments in bronchoscopy for early detection, accurate staging and treatment of lung cancer.

Increased expression of transforming growth factor-beta1 in small airway epithelium from tobacco smokers and patients with chronic obstructive pulmonary disease (COPD)

Tobacco smoke is believed to cause small airway disease and then chronic obstructive pulmonary disease (COPD), but the molecular mechanisms by which small airway obstruction occurs remain unknown. To study the gene expression levels of transforming growth factor (TGF)-beta1, a potent fibrogenic factor, in small airway epithelium from smokers and patients with COPD, we harvested highly pure samples of epithelial cells from small airways under direct vision by using an ultrathin bronchofiberscope BF-2.7T (outer diameter 2.7 mm with a biopsy channel of 0.8 mm in diameter). The expression levels of TGF-beta1 were evaluated by reverse transcription-polymerase chain reaction (RT-PCR). The mRNA levels of TGF-beta1 corrected by beta-actin transcripts were significantly higher in the smoking group and patients with COPD than those in nonsmokers (p < 0.01). Furthermore, among smokers and patients with COPD, TGF-beta1 mRNA levels correlated positively with the extent of smoking history (pack-years) and the degree of small airway obstruction as assessed by measurements of flow-volume curves. Immunocytochemistry of the cells demonstrated more intense stainings for TGF-beta1 in samples from smokers and patients with COPD than from nonsmokers. Spontaneously released immunoreactive TGF-beta1 levels from cultured epithelial cells were more elevated in subjects with a history of smoking and patients with COPD than in nonsmokers. Our study showed a close link between smoking and expression of TGF-beta1 in small airways. Our results also suggested that small airway epithelial cells might be involved in obstructive changes found in smokers and patients with COPD.

Characteristic modifications of the peripheral airways in patients with bronchial asthma in areas with air pollution

OBJECTIVE

Changes in the peripheral airways in patients with bronchial asthma who were living in the Kawasaki industrial zone, region with severe air pollution, were morphologically investigated in order to determine the pathological conditions of such bronchial asthma, in particular ascertaining the effect of air pollution.

METHODOLOGY

Studies were made of the morphological characteristics of the peripheral airways in patients with bronchial asthma who had resided for long periods in an area near Tokyo affected by air pollution.

RESULTS

The endoscopic findings of the peripheral airways were distinct, consisting of reddening, stenosis, pigmentation, pallor, lustrelessness and hypersecretion. The histological findings also differed from those in usual forms of asthma.

CONCLUSIONS

The bronchial asthma in the present patients appeared to be a totally different form from a morphological viewpoint, although it was quite similar to known types in its clinicophysiological features.

Increased expression of inflammatory mediators in small-airway epithelium from tobacco smokers

To study the inflammatory responses of small-airway epithelium in smokers, we harvested enough living epithelial cells (1.97 x 10(6) +/- 0.74 x 10(6)) with a new ultrathin fiberscope from the very peripheral airways of 22 current smokers and 17 subjects who never smoked after informed consent was obtained. The cells were keratin positive and composed mainly of nonciliated cells. The expression levels of inflammatory markers [interleukin (IL)-8 and intercellular adhesion molecule (ICAM)-1] were evaluated with RT-PCR. The magnitude of the mRNA levels corrected by beta-actin transcripts of IL-8 and ICAM-1 was significantly higher in the smokers than in the nonsmokers (P < 0.001). Furthermore, among current smokers, IL-8 mRNA levels correlated positively with the extent of smoking history [in pack. years (packs/day x no. of years of smoking); r = 0.754, P < 0.001]. Spontaneously released IL-8 and soluble ICAM-1 levels (n = 12) from cultured epithelial cells were elevated in subjects with a smoking history than in those without it (IL-8, 1,580 +/- 29.6 vs. 354 +/- 39.4 pg. 10(6) cells(-1). 24 h(-1); P < 0.001; soluble ICAM-1, 356.0 +/- 45.9 vs. 112.9 +/- 12.9 pg. 10(6) cells(-1). 24 h(-1); P < 0.01 by Student's t-test ). In contrast, the epithelial cells from the main bronchi did not show such differences between smokers and nonsmokers. Our study highlighted a close link between smoking and the expression of inflammatory mediators such as IL-8 and ICAM-1 in small airways. Our results also suggested that this new ultrathin bronchofiberscope promised a good approach for the evaluation of cellular changes in the small airways.

Clinical applications of 2D and 3D CT imaging of the airways--a review

Hardware and software evolution has broadened the possibilities of 2D and 3D reformatting of spiral CT and MR data set. In the study of the thorax, intrinsic benefits of volumetric CT scanning and better quality of reconstructed images offer us the possibility to apply additional rendering techniques to everyday clinical practice. Considering the large number and redundancy of possible post-processing imaging techniques that we can apply to raw CT sections data, it is necessary to precisely set a well-defined number of clinical applications of each of them, by careful evaluation of their benefits and possible pitfalls in each clinical setting. In diagnostic evaluation of pathological processes affecting the airways, a huge number of thin sections is necessary for detailed appraisal and has to be evaluated, and information must then be transferred to referring clinicians. By additional rendering it is possible to make image evaluation and data transfer easier, faster, and more effective. In the study of central airways, additional rendering can be of interest for precise evaluation of the length, morphology, and degree of stenoses. It may help in depicting exactly the locoregional extent of central tumours by better display of relations with bronchovascular interfaces and can increase CT/bronchoscopy sinergy. It may allow closer radiotherapy planning and better depiction of air collections, and, finally, it could ease panoramic evaluation of the results of dynamic or functional studies, that are made possible by increased speed of spiral scanning. When applied to the evaluation of peripheral airways, as a completion to conventional HRCT scans, High-Resolution Volumetric CT, by projection slabs applied to target areas of interest, can better depict the profusion and extension of affected bronchial segments in bronchiectasis, influence the choice of different approaches for tissue sampling by better evaluation of the relations of lung nodules with the airways, or help to detect otherwise overlooked slight pathological findings. In the exploration of the air-spaces of the head and neck, targeted multiplanar study can now be performed without additional scanning by retro-reconstructed sections from original transverse CT slices. Additional rendering can help in surgical planning, by simulation of surgical approaches, and allows better integration with functional paranasal sinuses endoscopic surgery, by endoscopic perspective rendering. Whichever application we perform, the clinical value of 2D and 3D rendering techniques lies in the possibility of overcoming perceptual difficulties and 'slice pollution', by easing more efficient data transfer without loss of information. 3D imaging should not be considered, in the large majority of cases, as a diagnostic tool: looking at reformatted images may increase diagnostic accuracy in only very few cases, but an increase in diagnostic confidence could be not negligible. The purpose of the radiologist skilled in post-processing techniques should be that of modifying patient management, by more confident diagnostic evaluation, in a small number of patients, and, in a larger number of cases, by simplifying communication with referring physicians and surgeons. We will display in detail possible clinical applications of the different 2D and 3D imaging techniques, in the study of the tracheobronchial tree, larynx, nasal cavities and paranasal sinuses by Helical CT, review relating bibliography, and briefly discuss pitfalls and perspectives of CT rendering techniques for each field.

Erythromycin modulates IL-8 expression in normal and inflamed human bronchial epithelial cells

Erythromycin (EM) and its 14-member macrolide analogues have attracted attention for its effectiveness in a variety of airway diseases, including diffuse panbronchiolitis (DPB), sinobronchial syndrome, and chronic sinusitis. However, its mechanisms of action remain unelucidated. We evaluated the effects of several antibiotics on IL-8 expression by normal and transformed human bronchial epithelial cells, an important source of this potent chemokine involved in cell recruitment into the airways. EM and clarithromycin (CAM) uniquely suppressed mRNA levels as well as the release of IL-8 at the therapeutic and noncytotoxic concentrations (% inhibition of IL-8 protein release: 25.0 +/- 5.67% and 37.5 +/- 8.99%, respectively, at 10(-6) M). The other antimicrobes, including a 16-member macrolide josamycin, showed no effect. Bronchial epithelial cells from very peripheral airways as well as from main bronchi were obtained from patients with chronic airway inflammatory diseases, and EM and CAM inhibited IL-8 release from these cells. Among five patients who underwent bronchoscopy before and after macrolide treatment, four showed decreased levels of IL-8 expression in airway epithelium as assessed by reverse transcription and polymerase chain reaction. Our findings showed these 14-member macrolides had inhibitory effect on IL-8 expression in human bronchial epithelial cells, and this new mode of action may have relevance to their clinical effectiveness in airway diseases.