Segmental Lavage Research Articles

P1‐56: A case of pulmonary alveolar proteinosis with severe respiratory failure improved by segmental lung lavage with fiberoptic bronchoscopy under general anesthesia

P1‐56: A case of pulmonary alveolar proteinosis with severe respiratory failure improved by segmental lung lavage with fiberoptic bronchoscopy under general anesthesia

Lipoid pneumonia in a gas station attendant.

The exogenous lipoid pneumonia, uncommon in adults, is the result of the inhalation and/or aspiration of lipid material into the tracheobronchial tree. This is often confused with bacterial pneumonia and pulmonary tuberculosis due to a nonspecific clinical and radiologic picture. It presents acutely or chronically and may result in pulmonary fibrosis. We describe here a case of lipoid pneumonia in a gas station attendant who siphoned gasoline to fill motorcycles; he was hospitalized due to presenting with a respiratory infection that was hard to resolve. The patient underwent bronchoscopy with bronchoalveolar lavage, which, on cytochemical (oil red O) evaluation, was slightly positive for lipid material in the foamy cytoplasm of alveolar macrophages. Due to his occupational history and radiographic abnormalities suggestive of lipoid pneumonia, a lung biopsy was performed to confirm the diagnosis. The patient was serially treated with segmental lung lavage and showed clinical, functional, and radiological improvement.

A Case of Alveolar Proteinosis in Which Cessation of Home Oxygen Therapy Was Possible After 2-Stage Segmental Lavage

A Case of Alveolar Proteinosis in Which Cessation of Home Oxygen Therapy Was Possible After 2-Stage Segmental Lavage

Pulmonary alveolar proteinosis and successful therapy with combined lavage procedures: Case reports

Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the accumulation of lipoproteinaceous material within alveolar spaces. Whole-lung lavage (WLL) has been the most common therapeutic intervention for this disorder. However, patients presenting with PAP are usually hypoxemic or in poor clinical condition, and WLL may be impossible to perform. In such cases, multiple segmental lavage (MSL) may be advocated as a first-choice therapy prior to WLL. Herein, we present two cases with idiopathic PAP treated successfully with both lavage techniques consecutively. After the MSL procedure, WLL was performed, and both patients showed a marked clinical and physiologic improvement. Therefore, for patients who are not good candidates for general anesthesia, we recommend MSL (or 'prewash') before WLL to produce an increase in the blood oxygen level for long-duration general anesthesia. In the surgical room, close monitoring and repositioning of the patient as well as maintenance and inspection of the correct tube position, and manual chest wall percussion are extremely important for the safety and success of the procedure.

Immunoglobulin E and eosinophilic cationic protein in segmental lavage fluid of the small and large bowel identify patients with food allergy.

Members of the general population often assume that they suffer from food allergy, but the true prevalence is low. Testing for the diagnosis of food-related hypersensitivity entails laborious procedures, including GI endoscopy. Our objective was to develop an endoscopic screening approach for food allergy. Endoscopically guided segmental lavage was performed in 11 patients with GI allergy and in 20 controls during lower GI endoscopy of the terminal ileum, the coecum, and the rectosigmoid. Eosinophilic cationic protein (ECP) and protein were measured in native lavage fluid, and immunoglobulin E (IgE) was also measured after a 10-fold lavage concentration. IgE/protein in lavage fluid from the coecum (0.055 +/- 0.068 U/mg vs 0.003 +/- 0.012 U/mg; p = 0.001) and the rectosigmoid (0.134 +/- 0.170 U/mg vs 0.019 +/- 0.042 U/mg; p < 0.05) was significantly elevated in patients with GI allergy. ECP/protein was significantly elevated at the terminal ileum (22.95 +/- 37.67 microg/mg vs 7.09 +/- 7.68 microg/mg; p < 0.05) and the rectosigmoid (23.66 +/- 19.43 microg/mg vs 11.97 +/- 16.39 microg/mg; p < 0.05). The combined use of GI lavage IgE and ECP as a diagnostic test for food allergy resulted in a sensitivity of 91% and a specificity of 80%. In endoscopically guided segmental lavage fluid, IgE and ECP/protein are increased in patients with food allergy. These measurements seem to offer an attractive diagnostic tool and may serve as a screening method.

Immunoglobulin E and eosinophilic cationic protein in segmental lavage fluid of the small and large bowel identify patients with food allergy

OBJECTIVE: Members of the general population often assume that they suffer from food allergy, but the true prevalence is low. Testing for the diagnosis of food-related hypersensitivity entails laborious procedures, including GI endoscopy. Our objective was to develop an endoscopic screening approach for food allergy. METHODS: Endoscopically guided segmental lavage was performed in 11 patients with GI allergy and in 20 controls during lower GI endoscopy of the terminal ileum, the coecum, and the rectosigmoid. Eosinophilic cationic protein (ECP) and protein were measured in native lavage fluid, and immunoglobulin E (IgE) was also measured after a 10-fold lavage concentration. RESULTS: IgE/protein in lavage fluid from the coecum (0.055 ± 0.068 U/mg vs 0.003 ± 0.012 U/mg; p = 0.001) and the rectosigmoid (0.134 ± 0.170 U/mg vs 0.019 ± 0.042 U/mg; p < 0.05) was significantly elevated in patients with GI allergy. ECP/protein was significantly elevated at the terminal ileum (22.95 ± 37.67 μg/mg vs 7.09 ± 7.68 μg/mg; p < 0.05) and the rectosigmoid (23.66 ± 19.43 μg/mg vs 11.97 ± 16.39 μg/mg; p < 0.05). The combined use of GI lavage IgE and ECP as a diagnostic test for food allergy resulted in a sensitivity of 91% and a specificity of 80%. CONCLUSIONS: In endoscopically guided segmental lavage fluid, IgE and ECP/protein are increased in patients with food allergy. These measurements seem to offer an attractive diagnostic tool and may serve as a screening method.

Density gradient centrifugation of colonic fluid after segmental lavage: a method of purification of exfoliative epithelial colonic cells for cytological interpretation and image cytometry in patients with long-standing ulcerative colitis.

Patients with extensive, long-standing ulcerative colitis (UC) have an increased risk for developing colorectal cancer. In this study, we wanted to establish a method for retrieving cytological material after segmental colonic lavage for further cytopathological investigations and for performing DNA image cytometry. Ten patients with long-standing and extensive ulcerative colitis and 10 patients without macroscopic abnormalities were investigated. After segmental colonic lavage during routine colonoscopy a three-layer (1.146, 1.075, and 1.046 g/ml, respectively) density gradient centrifugation of the retrieved colonic fluid was performed for isolation and purification of the epithelial cells. For identification of the epithelial cells flow cytometry with monoclonal antibody against cytokeratin and counterstaining with propidium iodine was performed. The smears obtained were stained for routine cytopathological interpretation and for DNA image cytometry. In eight of 10 UC patients and in nine of 10 control group patients adequate cytological material could be obtained. The band on top of the density gradient at 1.046 g/ml could be identified as the epithelial cells. Atypical cells were found in smears of three UC patients. In these patients and in one additional patient aneuploid stemlines could be detected. In smears of control group patients neither atypical cells nor aneuploidy were present. Isolation and purification of epithelial cells after segmental colonic lavage by using density gradient centrifugation was performed. This cytological material is adequate for cytopathological interpretation and for DNA image cytometry. Information about atypical cells and DNA aneuploidy as an additional marker of malignant transformation in UC patients was obtained. The combination of cytological examination and DNA image cytometry might improve the detection of UC patients with high risk for colorectal cancer.

Density gradient centrifugation of colonic fluid after segmental lavage: a method of purification of exfoliative epithelial colonic cells for cytological interpretation and image cytometry in patients with long-standing ulcerative colitis

Objectives: Patients with extensive, long-standing ulcerative colitis (UC) have an increased risk for developing colorectal cancer. In this study, we wanted to establish a method for retrieving cytological material after segmental colonic lavage for further cytopathological investigations and for performing DNA image cytometry. Methods: Ten patients with long-standing and extensive ulcerative colitis and 10 patients without macroscopic abnormalities were investigated. After segmental colonic lavage during routine colonoscopy a three-layer (1.146, 1.075, and 1.046 g/ml, respectively) density gradient centrifugation of the retrieved colonic fluid was performed for isolation and purification of the epithelial cells. For identification of the epithelial cells flow cytometry with monoclonal antibody against cytokeratin and counterstaining with propidium iodine was performed. The smears obtained were stained for routine cytopathological interpretation and for DNA image cytometry. Results: In eight of 10 UC patients and in nine of 10 control group patients adequate cytological material could be obtained. The band on top of the density gradient at 1.046 g/ml could be identified as the epithelial cells. Atypical cells were found in smears of three UC patients. In these patients and in one additional patient aneuploid stemlines could be detected. In smears of control group patients neither atypical cells nor aneuploidy were present. Conclusions: Isolation and purification of epithelial cells after segmental colonic lavage by using density gradient centrifugation was performed. This cytological material is adequate for cytopathological interpretation and for DNA image cytometry. Information about atypical cells and DNA aneuploidy as an additional marker of malignant transformation in UC patients was obtained. The combination of cytological examination and DNA image cytometry might improve the detection of UC patients with high risk for colorectal cancer.

Immediate and Late Airway Response of Allergic Rhinitis Patients to Segmental Antigen Challenge: Characterization of Eosinophil and Mast Cell Mediators

Segmental antigen bronchoprovocation was used to define the nature of the inflammatory process in allergic airway disease. Bronchoalveolar lavage fluid obtained from allergic rhinitis patients 12 min after segmental antigen instillation (immediate response) revealed a significant increase in histamine and tryptase, but no cellular response. Repeat segmental lavage 48 h later (late response) showed marked and significant increases in both low and normal density eosinophils as well as striking elevations of eosinophil granular protein levels (major basic protein, eosinophil-derived neurotoxin, eosinophil cationic protein, and eosinophil peroxidase). Leukotriene C4, but not tryptase, concentrations were also consistently elevated in late lavage samples. Further, the late lavage samples showed a significant increase in interleukin-5 concentrations that correlated with the presence of eosinophils and eosinophil granular proteins. Neither eosinophils nor soluble mediators of eosinophils increased when normal subjects were similarly challenged with antigen. These data suggest that eosinophils are attracted to the airway during the late-phase allergic reaction and that IL-5 may produce changes in airway eosinophil density and promote the release of granular proteins to cause airway injury.

Failure of Bronchial Lavage to Detect Elevated Levels of Adrenocorticotropin (ACTH) in Patients with ACTH-Producing Bronchial Carcinoids

Saline lavage of the major bronchial segments was performed in five patients immediately preceding lobectomy to remove an ACTH-producing bronchial carcinoid. Lavage fluid from each bronchus was concentrated, and ACTH determinations were performed. Elevated concentrations of ACTH were not demonstrated in the aspirate from the bronchus containing the known tumor. Two additional patients with ectopic ACTH syndrome from an unknown primary source also underwent selective segmental bronchial lavage for ACTH determination. Neither patient demonstrated ACTH gradients in the lavage specimens. One was found to have an ACTH-producing bronchial carcinoid 18 months after negative lavage. Selective segmental bronchoscopic lavage with measurement of ACTH levels on the aspirate is not an effective technique for detecting ACTH-producing bronchial carcinoid tumor.

Use of Segmental Airway Lavage to Obtain Relevant Mediators from the Lungs of Asthmatic and Control Subjects

Studies have demonstrated that increased amounts of histamine in the airways of asthmatic patients are associated with increased airway reactivity. However, using routine bronchoalveolar lavage (BAL), histamine can be detected in only a portion of asthmatic subjects and a minority of control populations. To obtain relevant mediators from the airways in higher concentrations by avoiding the dilution inherent with a standard BAL, a technique was developed to lavage isolated airway segments of the human lung that employed a double-lumen bronchoscope and a balloon-tipped catheter. Lavage fluid obtained by this method yielded significantly higher concentrations of histamine than that obtained with routine BAL (asthmatic subjects, 2,403 +/- 633 pg/ml vs 188 +/- 42 pg/ml; rhinitis subjects, 533 +/- 187 pg/ml vs 113 +/- 53 pg/ml; normal subjects, 174 +/- 63 pg/ml vs 11 +/- 11 pg/ml). Similar findings were also noted for prostaglandin D2 (PGD2). Segmental airway lavage also resulted in higher lavage fluid concentrations of LTB, than routine BAL. Segmental airway lavage should help in studying the relationship of mast cell degranulation to airways reactivity in both asthmatic and other study populations.

Bronchoalveolar lavage of the live anaesthetised sheep

Segmental lavage was performed on anaesthetised adult sheep using either endoscopic catheterisation or fibreoptic bronchoscopy. Cellular and humoral data were compared with results obtained from gross lavage of whole excised lungs. Both techniques proved rapid, convenient and reproducible, providing sufficient material for qualitative and quantitative assays of respiratory cells and fluid. Although total cells per unit volume of fluid obtained by catheterisation or by bronchoscopy were decreased compared with whole lung lavage, differential cell populations, fluid recovery and immunoglobulin and complement (C3) concentrations were comparable.

Cell-mediated immunity in pulmonary disease

According to one opera t ional model, the immune system of the lung may be viewed as existing in three distinct compartments (fig. I), each containing inmmnocompetent cells (lymphocytes and macrophages)l: 1) the bronchoalveolar air spaces; 2) the submucosa, or secretory antibody system, lying beneath the lamina propria of the tracheobronclfial tree; and 3) a network of lymphatic vessels and lymph nodes lining the tracheobronchial tree. Within each of these compartments, the potential exists for lymplmcyte-macrophage interaction and the generation of immune responses. In the last five years, most of our knowledge of cell-mediated immune responses in the lung has been derived fi'om studies of cells recovered from bronchoalveolar air spaces by segmental lavage in humans or by total pulmonary lavage in experimental animals, as reviewed recently. 2 Tints, much of this discussion focuses on studies of material derived from lavage.

Clinical Evaluation of Bronchopulmonary Lavage Using the Flexible Fiberoptic Bronchoscope

Thirty-three patients had segmental and lobar bronchopulmonary lavage using three types of flexible fiberoptic bronchoscopes. A maximum volume of 300 ml of normal saline solution at room temperature was used. Lavage was effective for removing large numbers of alveolar macrophages (mean, 17 million) and proteinaceous material (mean, 0.18 mg per milliliter) that helped enhance the antibacterial properties of the macrophages. Transient shunting (mean fall in partial pressure of arterial oxygen, 65 mm Hg) and alveolar filling that reverted to normal in 3 hours were noted. The procedure averaged 45 minutes and was as simple as bronchoscopy. The larger the internal diameter of the bronchoscope (< 2.6 mm) the better suited it was for lavage. Sequential segmental lavage seems to offer the advantages of simplicity and technical ease over isolated lobar lavage with a balloon-tipped bronchoscope. It also has the advantage of simplicity over whole-lung lavage.

Pulmonary alveolar proteinosis: the diagnosis by segmental lavage.

Histologic findings from segmental lavage material via the fiberoptic bronchoscope were evaluated as a means of diagnosing pulmonary alveolar proteinosis. Active cases of alveolar proteinosis yielded grossly opaque and/or milky effluents. The unique histologic findings in alveolar proteinosis included: (1) very few alveolar macrophages (2) large acellular eosinophilic bodies in a diffuse background of eosinophilic granules, and (3) periodic acid-Schiff staining of the proteinaceous material with a lack of significant alcian blue staining. Thus, the diagnosis of pulmonary alveolar proteinosis can be made by evaluation of the clinical setting and histologic findings of the effluent material from a segmental lavage.

The Role of Fiberoptic Bronchoscopy in the Diagnosis of Sarcoidosis: Clinical Conference in Pulmonary Disease from Ohio State University, Columbus

In an attempt to elucidate the nature of the pulmonary infiltrates, fiberoptic bronchoscopic examination was performed. At the time of the bronchoscopic procedure, the bronchial mucosa was noted to have a nodular cobblestone appearance throughout most of the major bronchi. Biopsy of the mucosa was performed without incident. Under fluoroscopic control the biopsy forceps was then directed into the infiltrate in the right lower lobe, and multiple transbronchial biopsies were performed. In addition, the bronchoscope was wedged in a subsegmentai bronchus and the area was lavaged with 150 ml of physiologic saline solution. A total of 33 × 106 Davis GS, Brody AR, Landis JN, et al: Quantitation of inflammatory activity in interstitial pneumonitis by bron-chofiberscopic pulmonary lavage. Chest (suppl 1): 265-266 Google Scholar bronchoalveolar cells were obtained by segmental lavage. A differential cell count of the bronchoalveolar cells revealed 68 percent alveolar macrophages, 31 percent lymphocytes, and 1 percent polymorphonuclear leukocytes. These findings were consistent with the presence of granulomatous inflammation in the lung. Subsequently, pathologic examination of the specimens from biopsies of the bronchial mucosa, lung, and breast revealed noncaseating granuloma consistent with sarcoidosis. Special staining reactions on all specimens from biopsies and cultures of bronchial washings were negative for organisms.

The effects of corticosteroid administration on the bronchoalveolar cells obtained from guinea pigs by lung lavage.

The effects of systemic administration of corticosteroids on the bronchoalveolar cell population obtained from guinea pigs by lung lavage were studied. The results of this study demonstrate that in contrast to the marked decrease in the percentage of T lymphocytes in the peripheral blood of animals treated with steroids, there was no significant decrease in the percentage of T lymphocytes in the bronchoalveolar cell population. In addition, corticosteroid administration did not significantly affect either the number of alveolar macrophages obtained by lavage or the Fc receptor activity of these cells. When considered in the context of previously reported data, these results emphasize that caution must be used in reaching conclusions about the integrity of the pulmonary immune response from the results of studies using a bronchoalveolar cell population obtained by lung lavage. This observation must be considered when evaluating the significance of studies of the human pulmonary immune response performed with cells obtained by segmental bronchopulmonary lavage.

Cancer in chronic ulcerative colitis

Saline colonic lavage in 74 patients with chronic ulcerative colitis was performed utilizing a commercially available dental irrigating unit through a polyethylene catheter in the biopsy channel of a colonoscope or through a sigmoidoscope via a lavage-aspirating double-lumen probe. Six patients were found with colonic carcinoma. Two diagnoses of malignancy were established by cytologic smears and cell block alone. Two patients had positive mucosal biopsies and cell block. One patient with a hepatic flexure carcinoma and a second patient with a malignancy proximal to the left colon stricture were missed by these techniques. Considering the established proclivity for carcinoma in these patients, it is felt that segmental lavage in areas of stricutre, grossly dostorted mucosa, or endoscopically inaccessible areas represents a valuable adjunct in the diagnosis of carcinoma in chronic ulcerative colitis.

Defective Lung Macrophages in Pulmonary Alveolar Proteinosis

Lung macrophages obtained by segmental lavage from three patients with pulmonary alveolar proteinosis were studied in vitro. The macrophages exhibited morphologic abnormalities including excessive lipid accumulation and giant secondary lysosome formation. These cells survived poorly in tissue culture, showed impaired chemotactic activity, and had decreased adhesiveness to glass. They phagocytized normally but had substantially decreased capacity to kill ingested Candida pseudotropicalis. Evidence was obtained that the macrophage defect was acquired and probably related to ingestion of the proteinaceous alveolar fluid. Peripheral blood monocyte function was normal in one patient and morphologic abnormalities were produced in normal monocyte-derived macrophages cultured with proteinaceous lavage material. These studies suggest that the lung macrophage in alveolar proteinosis is a defective cell as a consequence of an abnormal pulmonary environment.