A double blind, randomised, placebo controlled, crossover trial of prednisolone (40 mg/day for 14 days) was carried out in 33 patients with chronic airflow limitation (mean age 62 years, mean FEV1 1.01 litres, mean FEV1/FVC ratio 44%), to assess the value of serial peak expiratory flow (PEF) measurements, taken five times daily in evaluating treatment response by comparison with other objective measurements and with measurements of symptoms. The mean serial PEF after a one week run in period was 189 1 min-1, during the second week of placebo 193 1 min-1, and during the second week on prednisolone 231 1 min-1. The difference in mean PEF values between placebo and prednisolone was significant (p less than 0.01). With regard to the response to steroids of the individual patients, 13 of the 33 had a detectable trend of improvement on visual inspection of serial PEF measurements during prednisolone treatment but only one during placebo administration. Of all the objective measurements made after the run in and after each treatment phase (12 minute walking distance, FEV1, forced vital capacity (FVC), serial PEF), the serial PEF chart provided the best discrimination between placebo and prednisolone treatment. There was no statistically significant association between steroid induced improvement in serial PEF measurements and in breathlessness, partly because of placebo improvements in symptoms in those who had no improvement in serial PEF values. This study indicates the importance of making objective measurements to identify a genuine steroid response rather than relying on symptomatic improvement alone. The best simple measurement to make is serial PEF during steroid trials. This is more sensitive in detecting a steroid response than are the 12 minute walking distance, FEV1, or FVC, and is also less likely than these measurements to show spurious placebo responses.

Corticosteroids may produce mood changes. This could account for improvement in patients with chronic airflow limitation following trials of oral corticosteroid treatment as mood elevation might improve performance in objective measurements. This proposition was tested in 21 patients with chronic airflow limitation, who underwent detailed psychological assessment during a randomised controlled double blind crossover trial of the effect of prednisolone 40 mg daily compared with that of a placebo. Self rating visual analogue scales for various qualities of mood were completed before the study and after each phase in addition to depression and psychological symptom questionnaires. After treatment with the placebo, patients showed increases in cheerfulness (p less than 0.01) and sociability (p less than 0.01) and a decrease in depression (p less than 0.01). After treatment with prednisolone there were increases in cheerfulness (p less than 0.01), optimism (p less than 0.01), activity (p less than 0.05), and sociability (p less than 0.02) and there was a decrease in depression (p less than 0.01). When placebo and prednisolone values were compared, however, there were no significant differences. Some patients showed improvements (greater than 20%) in peak expiratory flow, FEV1 or forced vital capacity (FVC) after prednisolone, but nearly all had improvements in at least one psychological test. There were no detectable associations between changes in objective measurements and changes in psychological test ratings. This study suggests that in patients with chronic obstructive lung disease significant psychological changes are no more likely to follow treatment with a corticosteroid than treatment with a placebo and that physiological improvement after corticosteroid treatment is not tied to psychological changes.

A double-blind, randomised, placebo-controlled, crossover trial of prednisolone (40 mg daily for 14 days) was carried out in 43 patients with chronic airflow limitation (mean age 60 years, mean FEV1 1·02 litres, FEV1/FVC ratio 43·7%). Several subjective and objective variables for response were measured. Significant improvements occurred with prednisolone in most variables measured, but improvements also occurred with placebo in some variables. The improvements with prednisolone in general wellbeing, 12 min walk distance, peak expiratory flow, FEV1, and relaxed vital capacity were significantly greater than those with placebo. Clinical assessment and assessment of atopic status did not reveal any feature of major predictive value for steroid responsiveness. A proportion of patients with chronic airflow limitation do improve on oral corticosteroids and the continued use of such trials in clinical practice is justified, though a placebo period should be included, and several variables for response should be measured.

We report our experience with transbronchial biopsy using the Olympus BF-B3 fibrescope in 433 patients, who had 456 procedures performed at Brompton Hospital between April 1976 and July 1979. Two thirds of the patients were male; the mean age was 52 years. The transnasal route was used in the majority. In each case an appropriate subsegmental bronchus was selected and the biopsy forceps were pushed to the lung periphery or into the abnormal mass. A single plane x-ray image intensifier and Rotacor rotating table were used to enable accurate placement. Six to ten biopsies were taken in each case. Oxygen was administered by nasal cannula during the procedure. Blood was crossmatched routinely before each procedure and platelets and prothrombin time were checked.

Transbronchial lung biopsy was performed via the fibreoptic bronchoscope in 433 patients. In 183 patients, whose chest radiographs showed bilateral diffuse shadows a histologic diagnosis was established by transbronchial biopsy in 61%, including sarcoidosis (58), fibrosing alveolitis (18) and carcinoma (14). Histologically normal lung or inadequate pulmonary tissue for diagnosis was obtained from 71 patients in this group. In 225 patients with solitary chest radiography opacity, a diagnosis of bronchial carcinoma was finally made in 130, of whom 82 (63%) had a histological diagnosis established by transbronchial biopsy. In 84 patients finally shown to have sarcoidosis, 65 (77%) had positive histology by transbronchial biopsy whereas only 19 (40%) of 48 patients with fibrosing alveolitis yielded histology compatible with the diagnosis. Pneumothorax developed in three patients after the procedure but only one required intercostal drainage. Haemorrhage of 50-100 ml occurred in seven patients and bleeding ceased spontaneously in all cases. There were no fatalities.

It has been claimed that cusum analysis may be a clearer way of expressing trends in serial peak flow (PF) measurements in asthma than visual inspection of peak flow charts. To assess this we have applied cusum analysis to serial PF measurements in patients receiving various forms of treatment for airflow obstruction. We found that cusum analysis usually gave no additional advantage over simple graphs of PF data. In cases in which trends were apparent only by cusum analysis, their dimension was such that they were unlikely to form the basis of decisions on treatment.

Sarcoidosis was ultimately diagnosed in a consecutive series of 79 patients, of whom 24 presented with unusual features. Histological support for this diagnosis was obtained in 37 out of 42 patients who underwent transbronchial biopsy; epithelioid and giant-cell granulomas were also found on biopsy of the bronchial mucosa in 17 out of 22 patients. Kveim tests were completed in 44 patients: results were positive in 19, equivocal in 11, and negative in 14. In 16 patients histological support was obtained on biopsy of various other tissues. The clinical presentation of the disease and the degree of histological support provided by the various procedures used in reaching a diagnosis of sarcoidosis varied considerably. Transbronchial biopsy of the lung is a useful advance in diagnosing sarcoidosis and provided a higher diagnostic yield than any other method.

Fibreoptic bronchoscopy was introduced more than 10 years ago and is now in many centres a routine diagnostic procedure, having superseded rigid bronchoscopy. Its major role is in the diagnosis of bronchial carcinoma, where the results are as good as, if not better than, results with the rigid instrument. Other major applications have been found in investigating haemoptysis, transbronchial lung biopsy in interstitial lung disease, and in the critically ill patient in the intensive care unit. More recently, the instrument has been used to perform bronchoalveolar lavage in investigating interstitial lung diseases and to enable lobar and segmental lung function studies to be performed. Fibreoptic bronchoscopy is a major advance in the diagnosis of pulmonary diseases, but there will always be times when rigid bronchoscopy is preferable.

Fibreoptic bronchoscopy was introduced more than 10 years ago and is now in many centres a routine diagnostic procedure, having superseded rigid bronchoscopy. Its major role is in the diagnosis of bronchial carcinoma, where the results are as good as, if not better than, results with the rigid instrument. Other major applications have been found in investigating haemoptysis, transbronchial lung biopsy in interstitial lung disease, and in the critically ill patient in the intensive care unit. More recently, the instrument has been used to perform bronchoalveolar lavage in investigating interstitial lung diseases and to enable lobar and segmental lung function studies to be performed. Fibreoptic bronchoscopy is a major advance in the diagnosis of pulmonary diseases, but there will always be times when rigid bronchoscopy is preferable.