Initial Lavage Research Articles

Whole lung lavage in comparison with bronchoscopic lobar lavage using the rigid bronchoscope in patients with pulmonary alveolar proteinosis: Is it time to change strategy?

BackgroundPulmonary alveolar proteinosis (PAP) is characterized by accumulation of surfactant lipoproteins within the alveoli that leads to impaired oxygen transfer across the alveoli. Recent investigations showed that the most effective method of its treatment is the mechanical removal of surfactant material from the alveoli. Methods12 patients with PAP treated either with bronchoscopic lobar lavage (Group A, 5 patients) or whole lung lavage (Group B, 7 patients) from August 2006 till September 2016 were included. ResultsThe average lavage time was significantly shorter in Group B (2.5 ± 0.5 h) than Group A (4 ± 0.5 h). Also the average lavage volume was significantly bigger in group B (17 ± 1 L) than in group A (9 ± 1.5 L). The average hospital stay in group B was significantly longer (10 ± 2 d) than in group A (5 ± 2 d). All patients could be followed up in a mean period of 62.3 ± 21.2 months. In group A, 4 patients required relavage within 2 years of the initial lavage, while in group B one patient (14.25%) required relavage within 2 years and 2 patients (28.5%) within 3 years. These results were of statistically significant difference. ConclusionWhole-lung lavage is more efficient than bronchoscopic lobar lavage in treating PAP as it provides larger lavage volumes in shorter time periods and is also associated with lower rate of recurrence of symptoms and the need of relavage.

Paradoxical response as a cervical lymph node enlargement after termination of anti-tuberculosis treatment in a patient with pulmonary tuberculosis

A paradoxical response is not uncommon in non-HIV-infected patients, particularly those with extra-pulmonary tuberculosis. It is defined as the radiological and clinical worsening of a previous lesion or the development of new lesion during anti-tuberculosis therapy. The paradoxical response has been attributed to host immunologic reactions, such as a delayed hypersensitivity or a response to mycobacterial antigens. In most reports of paradoxical response, these responses occurred in the same location as a previous lesion. In this patient with pulmonary tuberculosis, cervical lymph node enlargement occurred as a paradoxical response after the completion of anti-tuberculosis treatment. Although the new lesion developed in another location, it could be considered as a paradoxical response based on the negative culture result of acid fast bacilli from the new lesion and drug sensitivity result from initial bronchoalveolar lavage specimen. Therefore we were able to decide on the termination of unnecessary anti-tuberculous treatment. Based on our case, we can conclude that paradoxical response can occur after the termination of anti-tuberculosis therapy even in new site.

Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult.

A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis.

Gastrointestinal perforation in neonates: aetiology and risk factors.

Gastrointestinal perforation (GIP) in neonates presents important challenges and mortality can be high. This is a report of recent experience with GIP in neonates in a developing country. A retrospective review of 16 neonates treated for GIP in a 3 year period. There were 9 males and 7 females, aged 0-28 days (median age =7days). Their weights at presentation ranged from 0.9 - 4.7kg (median =2.6). Five infants were premature. Twelve infants presented more than 72 hours after onset of symptoms. Plain abdominal radiographs showed peumoperitoneum in 9 infants. The cause of perforation was necrotising enterocolitis 6, intestinal obstruction 6, iatrogenic 3 and spontaneous 1. The site of perforation was ileum in 12 infants, stomach in 4 and colon in 4; 4 patients had involvement of more than one site. All the neonates underwent exploratory laparotomy with primary closure ( n=5) , resection and anastomosis( n=6), colostomy (n=3), Ileostomy ( n=2), partial gastrectomy (n=2) ,or gastrojejunostomy ( n=1). Two neonates had multiple procedures. Two very sick preterm babies had an initial peritoneal lavage. Surgical site infection is the commonest postoperative complication occurring in 9 infants. Anaesthesia sepsis and malnutrition is responsible for the seven deaths recorded. Neonatal GIP has multiple aetiologies; NEC is the most common cause. Major mortality risk factors include NEC, multiple perforations, delayed presentation and prematurity.

A Comparison of Abdominal Cavity Bacterial Contamination of Laparoscopy and Laparotomy for Colorectal Cancers

Background/Aim: To compare intra-abdominal remnant bacterium between laparotomy and laparoscopic colorectal surgery. Methods: 72 patients with nonobstructive colorectal cancer were divided into two groups: laparotomy (47 cases) and laparoscopic surgery (25 cases). At the beginning of the operation just after the laparotomy incision was made or the trocars were inserted, 10 ml saline was irrigated into the Douglas pouch and collected through Nelaton’s catheter. Just before closing the wound, 10 ml saline was collected in the same way as the initial lavage in both groups. The collected saline as a specimen was determined to obtain the number of surviving bacterium. Results: No growth of bacteria was observed at the beginning of both operations. The remnant bacterial detection rates from the lavage fluid collected just before closing the wound were 23 of 47 cases (49%) in the laparotomy group and 7 of 25 cases (28%) in the laparoscopic surgery group; higher detection was observed in the laparotomy group. The mean bacteria cell counts after lavage were 4.6 × 10⁶ CFU/ml of aerobic bacteria and 1.9 × 10³ CFU/ml of anaerobic bacteria in the laparotomy group and 1.8 × 10⁴ CFU/ml of aerobic bacteria and 1.6 × 10² CFU/ml in the laparoscopic surgery group: the laparotomy group demonstrated an apparently higher number of remnant bacterium. Conclusions: In colorectal resections, laparoscopic surgery demonstrated a lower incidence of intra-abdominal contamination than laparotomy.

Ethanol Pancreatic Injection of Cysts (EPIC): Preliminary Results of a Prospective Multicenter, Randomized, Double Blinded Study

Background/Aims: Pilot data from EUS-guided ethanol lavage (EUS-EL) of pancreatic cystic lesions (PCLs) suggested that cyst resolution and epithelial ablation may be achieved as demonstrated by imaging and surgical pathology. Aim: To validate these data in a multicenter, randomized double-blinded study. Hypothesis: EUS-EL with 80% ethanol will decrease the size and cyst fluid CEA of PCLs by ≥25%, more often than saline lavage (EUS-SL) at 3 months following treatment. Methods: Patients referred for EUS of a 10-50 mm PCL with 0-4 septations were randomized to 5 minute EUS-EL #1 or EUS-SL #1. The patient and physician were blinded to the identity of the lavage agent (ethanol or saline). Cyst fluid was evaluated for CEA, amylase and cytology. Subjects were contacted twice within the next week. Those managed medically returned at 3 months for re-measuring of cyst size, cyst aspiration and fluid analysis and 5 minute EUS-EL #2. Follow-up CT was repeated every 3-6 months. Surgery was allowed at any time during the study. The clinical diagnosis of PCLs was made by a combination of imaging morphology, cytology, cyst fluid CEA and/or surgery. Results: From 10/04-9/06, 51 patients were consented, 12 were excluded prior to initial lavage and 39 (26 F; mean age:69 yrs) with suspected mucinous (32) or nonmucinous (4) pancreatic cystic tumors and pseudocysts (3) were randomized to EUS-EL (23) or EUS-SL (16). Cyst size: median 19 mm (range: 10-40) and location: head/uncinate (17), body (15) or tail (7). The frequency of a decrease in cyst size and cyst fluid CEA of ≥25% at 3 months after randomization and complications with treatment are shown in Table 1. EUS-EL #2 was completed in 18 (78%) and 12 (75%) initially randomized to EUS-EL or EUS-SL, respectively. Complications from EUS-EL #2: abdominal pain (3), including acute pancreatitis in one. Surgical pathology in 2 who underwent PCL resection after EUS-EL: 1) benign 35 mm IPMN-Br in the tail with histology showing 50-75% epithelial ablation and; 2) benign 22 mm MCN in the uncinate with histology showing 100% epithelial ablation. Imaging following EUS-EL #2 demonstrated complete resolution of 5 suspected mucinous tumors and 1 pseudocyst. Conclusion: EUS-EL decreased pancreatic cyst size with few complications and may result in histopathologic epithelial ablation. In a subset (22%), complete resolution was achieved. Tabled 1Table 1 EUS-EL #1 (n = 23) EUS-SL #1 (n = 16) p-value Cyst diameter ↓ ≥25% 61% 17% 0.025 Cyst fluid CEA ↓ ≥25% 38% 40% 1.0 Abdominal pain 22% 19% 1.0 Pancreatitis 4% 0% 1.0 Cyst resolution by follow-up imaging after EUS-EL #2 22% 8% 0.6 Open table in a new tab

The use of a membrane oxygenator with extracorporeal circulation in bronchoalveolar lavage for alveolar proteinosis

Alveolar proteinosis is a rare pulmonary disease, characterised by the accumulation of a proteinaceous material in the alveoli, which severely reduces gas exchange and causes progressive disability of the patient, usually moderate, but sometimes completely disabling. Whole-lung lavage (WLL) is the preferred technique for the treatment of this disease, and it is performed by introducing into the lungs and draining a fluid (saline), which removes the phospholipidic material present in the alveoli, offering the patient a marked improvement in a short period of time. Sometimes the whole-lung lavage technique is not well tolerated by the patient, requiring the support of a membrane oxygenator during the course of the procedure. Few successful cases have been published. We report the case of a 33-year-old man with severe hypoxaemia who suffered cardiopulmonary arrest after the first attempt of bronchoalveolar lavage (BAL) and required support by means of extracorporeal venovenous circulation with a membrane oxygenator (ECMO). An initial incomplete lavage was performed with ECMO support, but the patient was re-admitted 7 months later and we performed a second WLL of both lungs in the same session, again using ECMO. Also, the BAL technique and its association with ECMO when necessary are reviewed.

Reproducibility of cytologic atypia in repeat nipple duct lavage

It is believed that atypical cells identified by nipple duct lavage (NDL) indicate an increased risk for breast carcinoma similar to atypical ductal hyperplasia diagnosed by tissue biopsy, but many basic performance characteristics of NDL currently are undefined. NDL was performed in 108 patients unselected for breast carcinoma risk and then was repeated after 2-14 months (median, 8 months) if the initial lavage was classified as atypical. Breast magnetic resonance images (MRIs) were obtained from a subset of patients who had atypical lavage results. Marked atypia was diagnosed in 22% of 36 breasts with an incident carcinoma compared with 7% of 172 unaffected breasts (P = 0.01). After excluding breasts with an incident carcinoma, there were 32 patients (30%) with either mild or marked atypia. The lavage was repeated in 23 of these women, and the second lavage was classified as atypical in 48%. Neither marked atypia on the initial lavage nor a 5-year Gail risk > or = 1.7% predicted atypia on repeat lavage, but there was a trend for improved reproducibility when the atypia initially was diagnosed in a fluid-producing duct. MRIs were abnormal in 13% of 24 breasts with an atypical lavage, and ductal carcinoma in situ was diagnosed subsequently in 1 breast. Atypia frequently is diagnosed by NDL, but the reproducibility of repeat lavage is low. Lavage atypia may be physiologic or artifactual rather than pathologic in many instances. Marked atypia occasionally may represent mammographically occult ductal carcinoma in situ.

Complement activation in the nasal mucosa following nasal ragweed-allergen challenge.

The aim of this study was to explore complement activation in the nasal lavage following a nasal ragweed-allergen challenge. The study was carried out with 15 adolescents who were allergic to ragweed and with six non-allergic healthy volunteers. Following the baseline measurement after the symptoms were registered, subjects were given increasing doses of ragweed allergen. Lavage fluid was collected and tested for a complement-activation product (C3bBbP). The allergic patients responded to allergen provocation with an increase in C3bBbP formation compared to the initial lavage (p = 0.001). The C3bBbP level remained low in the lavage fluids of the non-allergic controls. We found a strong correlation between the threshold dose that induced symptoms and the dose where the maximum complement activation was detected (r = 0.78, p = 0.001). Our findings indicate that in allergic patients nasal challenge with ragweed allergen induces a rise in complement activation in the nasal lavage fluid. These results highlight the role of the complement system in the allergic inflammation on the nasal mucosal surface.

Pulmonary alveolar proteinosis: a spectrum of cytologic, histochemical, and ultrastructural findings in bronchoalveolar lavage fluid.

Pulmonary alveolar proteinosis (PAP) is defined as abundant extracellular proteinaceous periodic acid-Schiff (PAS)-positive material which represents surfactant distending alveolar spaces. While this lesion is defined by histologic findings, there are characteristic radiologic features and cytologic findings in bronchoalveolar lavage (BAL) specimens that together may provide a confident diagnosis. The BAL specimens from all patients for which a diagnosis of PAP was made or suggested on either cytologic or biopsy specimens at University of North Carolina Hospitals from 1990-1999 were reviewed. There were 23 cytologic specimens from 11 patients. Patient ages ranged from 6 wk to 76 yr. All 23 specimens had slides prepared for Papanicolaou stain, 22 specimens (all patients) had Diff-Quik stains, 10 specimens (6 patients) had PAS stains, and 8 specimens (5 patients) had lipid stains. Nine patients had lung biopsies in addition to cytologic specimens. The clinical charts of all patients were reviewed. Twenty-one cytologic specimens were described as cloudy or milky, and 2 were bloody. By chart review and/or biopsy results, 8 patients were felt to have definite PAP. The initial lavage specimens from 6 of these patients showed classic cytologic findings of PAP, consisting of paucicellular specimens dominated by adundant extracellular granular to globular material which was basophilic on Diff-Quik stain, pale to focally eosinophilic on Pap stain, and PAS-positive, diastase-resistant. Five of these patients had biopsies; 3 showed PAP, and 2 were insufficient. Later BAL specimens after therapeutic lavage from these patients were often less characteristic, with scant extracellular material present. The other 2 patients with PAP clinically and by biopsy had atypical cytologic findings, with one showing numerous macrophages with scant PAS-positive material and abundant lipid mimicking lipid pneumonia, and one showing moderate eosinophils in addition to the extracellular proteinacous material. The remaining 3 patients were felt not to have PAP clinically or by biopsy (1 lymphocytic interstitial pneumonitis, 1 rheumatoid lung, and 1 hemosiderosis), and their BAL specimens predominantly contained macrophages with rare proteinaceous extracellular globules. Electron microscopy was performed in 5 patients (4 considered to have PAP, and 1 with lymphocytic interstitial pneumonitis) and in all cases showed whorled myelin figures characteristic of surfactant. The PAP cases and the non-PAP case had identical ultrastructural findings. We conclude that BAL specimens with classic cytologic features and supporting clinical and radiographic evidence may be diagnosed as PAP. Atypical specimens should be approached with caution, and may represent either PAP or other pulmonary diseases with secondary accumulation of surfactant. Cytology specimens taken subsequent to therapeutic lavage from PAP patients may also not be diagnostic.

Assessment of cellular profile and lung function with repeated bronchoalveolar lavage in individual mice.

In this study, we sought to develop procedures that would enable repeated bronchoalveolar lavage (BAL) in individual mice on multiple occasions. To achieve this objective, we first developed the procedures that would allow individual mice to survive a whole lung lavage, and then tested whether, on subsequent days, there was an effect of this initial BAL on the cell profile, lung permeability, and baseline respiratory function. Our results demonstrate that the repeated lavage procedure can be readily carried out in individual mice of different strains on multiple occasions. The lavage procedure itself results in immediate increases in respiratory system resistance and concomitant decreases in compliance, but these parameters return to prelavage values by the 2nd or 3rd day postlavage. Lavage also induces variable increases in inflammatory cells depending on the strain used. However, in all three strains examined here (A/J, BALB/c, and C3H/HeJ), inflammatory cell numbers returned to baseline values within 3 days after an initial lavage procedure. The ability to perform repeated BAL in individual mice should prove to be an extremely useful tool in a variety of functional genomic studies in the lung.

Intrapulmonary Cytokine Accumulation Following BAL and the Role of Endotoxin Contamination

BAL induces alveolar inflammation, but its effects on intrapulmonary cytokines and the mechanisms causing inflammation are uncertain. The objectives of this study were: (1) to characterize cytokine response in the lungs to BAL, and (2) to determine whether endotoxin is introduced into the lungs during BAL, which could promote BAL-induced inflammation. We performed two BAL procedures in healthy volunteers separated by 4 (n=6), 24 (n=5), or 72 h (n=3). The initial BAL was performed in the right middle lobe (RML) and the second BAL was performed in the same location and the lingula. Concentrations of interleukin-8 (IL-8), interleukin-1 (IL-1beta), and transforming growth factor-beta were measured by enzyme-linked immunosorbent assay and tumor necrosis factor-alpha (TNF-alpha) bioactivity was determined. Endotoxin contents of saline (10 and 20 mL) infused through bronchoscopes as well as BAL fluids recovered from six subjects were assessed by limulus amebocyte assay. At 4 h after the initial lavage, but not at later times, BAL fluid recovered from the RML contained increased concentrations of IL-8 and IL-1beta, and increased TNF-alpha bioactivity. BAL fluid recovered from the lingula contained increased concentrations of TNF-alpha only at 4 h. All BAL samples tested contained detectable endotoxin as did all saline aliquots instilled through bronchoscopes. There is intrapulmonary accumulation of the cytokines TNF-alpha, IL-8, and IL-1beta in the lavaged lung within 4 h after BAL; this accumulation resolves by 24 h. Endotoxin contamination of the lungs during bronchoscopy may contribute to BAL-induced lung inflammation.

The kinetics of grain dust-induced inflammation of the lower respiratory tract.

To characterize the kinetics of grain dust-induced airflow obstruction and inflammation in the lower respiratory tract, we performed serial spirometry and bronchoalveolar lavage (BAL) in human subjects and whole-lung lavage in mice following a single inhalation exposure to comparable dosages of corn dust extract (CDE). Following inhalation of CDE, our human study subjects developed significant airflow obstruction 10 min postexposure which persisted for 48 h. Human subjects and mice had similar acute and persistent changes in lavage cellularity after exposure to CDE. A profound increase in the concentration of lavage neutrophils was present in the initial postexposure lavage in both human subjects and mice. This increase persisted for 96 h in human subjects and 48 h in mice. Small but significant increases in lavage macrophage concentration were present 48 h postexposure in human subjects and at 96 h postexposure in mice. Inhalation of CDE resulted in a significant increase in the concentration of proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) in the lavage fluid of both human subjects and mice. Similarly, significant increases in lavage concentrations of IL-8 in humans and macrophage inflammatory protein-2 (MIP-2) in mice occurred after inhalation of CDE. The lavage concentration of all measured proinflammatory cytokines returned to baseline levels by 168 h in humans and 96 h in mice. These findings suggest that a single inhalation challenge of CDE results in airflow obstruction and lower respiratory tract inflammation that may last for several days. These physiologic and inflammatory responses appear to be self-limited with no evidence of persistent injury 1 wk after the inhalation challenge. Moreover, the inflammatory response in the lower respiratory tract after inhalation of grain dust is similar in human subjects and mice, suggesting that the mouse may be an appropriate model for further investigation of grain dust-induced inflammation.

Changes in the inflammatory response of the lung during acute respiratory distress syndrome: prognostic indicators.

We studied paired bronchoalveolar lavage (BAL) in patients with sepsis-associated acute respiratory distress syndrome (ARDS). Patients were evaluated at one institution and underwent bronchoscopy with BAL within 48 h of the onset of ARDS. Patients were restudied with bronchoscopy and BAL after 4 d of treatment. Fifty-eight patients were initially studied, with 44 patients having follow-up bronchoscopy after 4 d. The overall 30-d survival for the ARDS group was 60%. In the initial lavage, there was no difference in the neutrophils between the survivors and nonsurvivors (survivors: 59 [0-98]%; Median [Range]; nonsurvivors: 55 [0-92]%). The follow-up lavage demonstrated a significant drop in the neutrophils for the survivors (36 [4-89]%, p < 0.002) which was not seen for the nonsurvivors (70 [26-95]%). Initial IL-8 concentrations in the BAL fluid were not significantly different between the two groups. In the follow-up lavage, there was a significant fall for the IL-8 concentrations for the survivors but not the nonsurvivors. We conclude that neutrophil influx in ARDS may rapidly resolve within a week of the onset of ARDS. The resolution of neutrophils was associated with a good prognosis.

Idiopathic Pulmonary Fibrosis: Abnormalities in the Bronchoalveolar Lavage Content of Surfactant Protein A

Idiopathic pulmonary fibrosis (IPF) is a progressive disease of the lung characterized by an inflammatory infiltrate, alveolar type II cell hypertrophy and hyperplasia, and ultimate parenchymal scarring. The phospholipid composition of the surface-active material recovered by bronchoalveolar lavage (BAL) is abnormal in this disease. In the present study we have extended the analysis of surfactant components in IPF to include the major surfactant-associated protein, surfactant protein A (SP-A). SP-A has been reported to be essential for the formation of tubular myelin, to facilitate the adsorption of phospholipid to the air/liquid interface, and to stimulate uptake and inhibit secretion of surfactant in vitro. The BAL of 25 normal volunteers and 42 patients with interstitial lung disease (ILD) was analyzed for surfactant protein A content by ELISA and for phospholipids. The changes in BAL components were correlated to histopathologic markers at open-lung biopsy, clinical status, and survival. The total phospholipid (PL) recovered at lavage was reduced in patients with IPF relative to normal volunteers (p less than 0.0005). In addition, the percentage of phosphatidyl-glycerol (% PG) was decreased in patients with IPF (p less than 0.0001), whereas the percentage of phosphatidylcholine that was saturated was not altered. The content of surfactant protein A in lavage was reduced, even when normalized for the total amount of surface-active material recovered (SP-A/PL) (p less than 0.007). The reduction in SP-A was not specific to IPF but also occurred in other interstitial lung diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

Is Initial (24 Hours) Lavage Necessary in Treatment of CAPD Peritonitis?

A randomized trial was conducted to examine the influence of initial lavage on treatment of CAPD peritonitis. Patients with hypotension and shock were excluded from the trial. Thirty-six CAPD patients with acute peritonitis were randomized to treatment with intraperitoneal antibiotics including either initial 24 hours lavage before resumption of routine CAPD schedule (prior standard approach) or continued prolonged exchanges as in routine CAPD schedule. Median time to solved infection (normalization of white cell count in dialysis effluent) was identical (3 days) in the two groups. Treatment success rate was found to be 72% in the group with initial lavage and 89% in the group with prolonged exchanges. The difference in treatment success (17%) in favour of continued CAPD schedule was not found significant (95% confidence limits--1% to 35%). The results suggest lavage to be of no clinical benefit in treatment of CAPD peritonitis in patients without profound hypotension and shock.

Changes in alveolar macrophage, monocyte, and neutrophil cell profiles after smoke inhalation injury.

Thirty two fire victims with smoke inhalation, with or without burns, and 26 control subjects had bronchoalveolar lavage performed. Cell yields and differential cell counts were assessed. All patients and controls were cigarette smokers. Patients with smoke inhalation (SI) injury generally showed higher total bronchoalveolar lavage (BAL) cell yields, and this was significant on repeat lavage from 12 patients. The increase was almost entirely due to an increase in the proportion of neutrophils in patients with smoke inhalation alone (S) and those with cutaneous burns as well as smoke inhalation (S + B). On sequential lavage of 12 patients with smoke inhalation (SI) the proportion of neutrophils had increased; this was significantly higher than on initial lavage. Using various macrophage markers, the proportions of macrophage subgroups were determined. There was an increase in UCHM1 and RFD9 positive cells in each subgroup: the increase in UCHM1 positive cells was significant in patients with burns as well as smoke inhalation, and the increase in RFD9 positive cells was significant in patients with smoke inhalation alone. Assessment of the role of such cells in the development of acute lung injury (such as adult respiratory distress syndrome) may be important in our understanding of the mechanisms entailed.

Pulmonary fibrosis in a patient treated with bumetanide: clinical improvement associated with transition from a granuclocytic to lymphocytic alveolitis

Responses of the lung to injury are limited. Initial responses are usually inflammatory, and persistence of the injury may lead to fibrosis. Efforts to relate the cellular characteristics of the inflammatory alveolitis associated with pulmonary fibrosis (PF) or cryptogenic fibrosing alveolitis to the response to therapy and outcome have produced varying results. A granulocytic alveolitis composed of either neutrophils or eosinophils has been associated with a poorer prognosis and response to therapy than a lymphocytic alveolitis. However, mechanisms that lead to an alteration in the evolution of the alveolitis and lung injury remain unclear. We have studied a woman with PF in whom clinical and objective measures improved in association with a transition from an initial bronchoalveolar lavage (BAL) neutrophilia and eosinophilia to a BAL with a lymphocyte predominance. Due to the temporal relationship, the use of bumetanide was implicated in the development of PF.

Bronchoalveolar lavage cell counts as a predictor of short term outcome in pulmonary sarcoidosis.

Sixty seven patients with biopsy proven pulmonary sarcoidosis were prospectively studied to determine whether single point bronchoalveolar lavage cell counts were a useful indicator of functional outcome and whether repeated lavage helped in management. The mean follow up period was 25 (range 13-37) months. No patient was having corticosteroid treatment at the time of initial bronchoalveolar lavage. "High intensity alveolitis" (lymphocyte count greater than or equal to 28%) was present at the initial lavage in 42 patients. These patients showed a significant improvement in their pulmonary function and chest radiographs over the follow up period whereas patients with "low intensity alveolitis" did not. Of the 42 patients with high intensity alveolitis, 31 had chronic sarcoidosis (duration over two years, mean 80 months). These patients showed a significant improvement in FVC but not in TLCO. Corticosteroids resulted in greater functional and radiological improvement in the patients with high intensity alveolitis than in those with low intensity alveolitis. Repeat bronchoalveolar lavage in 34 patients, mean 8.4 months after the original lavage, showed a weak inverse relation between a reduced lymphocyte count and change in forced vital capacity and isotope uptake on a gallium scan. These correlations were too weak to make repeated cell counts useful in management. Our results suggest that high intensity alveolitis may be a favourable prognostic factor for lung function in pulmonary sarcoidosis, even in patients with chronic disease, but that repeat lavage adds little to the management of the individual patient.

Type 3 Procollagen Peptide in Bronchoalveolar Lavage Fluid: Poor Indicator of Course and Prognosis in Sarcoidosis

To investigate the role of bronchoalveolar lavage type 3 procollagen peptide as a prognostic indicator in sarcoidosis, we measured type 3 procollagen N-terminal peptide levels in lavage fluids from 84 sarcoidosis patients and monitored disease progress in these patients for a period of 12 months. Lavage procollagen peptide levels were significantly elevated in sarcoidosis patients compared to control subjects (p less than 0.001). No association was observed between lavage type 3 procollagen peptide and disease severity, as assessed by lung function tests. Follow-up monitoring of patients failed to demonstrate any relationship between subsequent functional deterioration and initial lavage type 3 procollagen peptide. These results suggest that elevated lavage type 3 procollagen peptide concentrations in sarcoidosis may reflect increased type 3 collagen synthesis associated with the inflammatory process rather than signal an early event in the development of chronic disease.