Utility Of Bronchoalveolar Lavage Research Articles

The Role of Bronchoalveolar Lavage in the Microbiological Diagnosis of Pneumonia in Patients with Haematological Malignancies

In the aetiological diagnosis of pulmonary infections in patients affected by haematological malignancies we evaluated the utility of bronchoalveolar lavage (BAL). One hundred and twenty-seven BAL were performed in 119 patients. In our series, we identified the agent of pneumonia in 53.5% of episodes with the best results in aspergillosis, very common in these patients. The previous empirical anti-infective treatment was modified in 14 episodes (11%). The procedure was generally well tolerated and only one patient bled. We maintain that BAL is a useful diagnostic tool for detecting the agents of pulmonary infections in patients with haematological malignancies, especially when the routine microbiological procedures fail, and it also represents a good alternative to more invasive procedures.

Role of bronchoalveolar lavage in the diagnosis of fat embolism syndrome.

Fat embolism syndrome (FES) is a serious clinical disorder occurring in trauma patients. The diagnosis of fat embolism syndrome may be difficult to establish clinically. We therefore wanted to investigate the usefulness of bronchoalveolar lavage (BAL) in the diagnostic evaluation of fat embolism syndrome. We analysed the presence of fat droplets in BAL cells in 32 trauma patients (7 with full diagnostic criteria of fat embolism syndrome, 17 with incomplete diagnostic criteria, and 8 with no diagnostic criteria at the time of bronchoscopy), 9 nontrauma patients with acute respiratory failure and radiographic pulmonary infiltrates, and a control group composed of 10 individuals. An increased percentage of oil red O positive alveolar macrophages (cut-off point > 3%) in BAL was found in 6 out of 7 patients with definite clinical criteria of fat embolism syndrome, and in 6 out of 20 trauma patients without the clinical diagnosis of fat embolism syndrome. In two patients with fat embolism syndrome, sequential BAL showed that the percentage of positive macrophages decreased when the clinical manifestations disappeared. An increased number of BAL macrophages with fat droplets was also observed in two trauma patients without evidence of fat embolism syndrome after long-bone surgical intervention. By contrast, all non-trauma patients had a percentage of positive cells lower than 3%. Our findings suggest that BAL oil red O positive macrophages are frequently observed in trauma patients irrespective of the presence of fat embolism syndrome. Conceivably, a high number of oil red O positive macrophages could reflect clinically silent fat embolization.

Bronchoalveolar lavage in pulmonary tuberculosis: a decision analysis approach

We assessed the utility of bronchoalveolar lavage (BAL) in the diagnosis of pulmonary tuberculosis (PTB) in 50 consecutive HIV-negative patients with clinical and radiographic findings suggestive of PTB, but with negative microscopy for acid-fast bacilli (AFB) on sputum smear. Patients were grouped, using a scoring system, into relative likelihoods of having PTB (I-IV, in descending probability). Patients were started on anti-tuberculosis treatment according to the BAL results. Bacteriological diagnosis of PTB was confirmed in 22/50 BAL; 11 (91.6%), seven (37%) and four (40%) of groups I-III, respectively. In 13 cases, an early diagnosis of PTB was made by positive microscopy for AFB on BAL; an alternative diagnosis was made in six cases (bacterial pneumonia 4, carcinoma 2). A decision analysis model was created to assess the overall utility of BAL. This suggested that in a region of high PTB prevalence, and when the clinical diagnosis of PTB is likely, empirical treatment is the best course of action, with BAL being reserved for further investigation of non-responders. Early BAL should be considered when the diagnosis of PTB is uncertain.

The efficacy of bronchoalveolar lavage in the diagnosis of pulmonary tuberculosis

In order to analyze the usefulness of bronchoalveolar lavage (BAL) for conventional microbiological diagnosis of tuberculosis (TB) and other mycobacteria, and to assess the need to use it or not as a routine diagnostic technique in these diseases, we studied 30 patients with mycobacteria (26 TB and 4 Mycobacterium avium-intracellulare infections) by bronchoscopy, with BAL and bronchoaspirate (BAS) bacteriological analyses also available. The results were compared with those obtained for sputum taken before and after bronchoscopy when these specimens were available. The overall yield for BAL and BAS cultures was 90%, with BAL (83.3%) specimens being more productive than BAS (73.3%) specimens. Both performed far better than the 53.8% recorded for cultures of pre-bronchoscopy sputum and 60% for post-bronchoscopy sputum. BAL was the only diagnostic specimen from 7 patients, while BAS the only one from 4. Sensitivity was similar for the two mycobacteria studied. The results for direct bacilloscopy, however, at 30% for the two specimens, rose to 36.6% when they were analyzed together with BAS and BAL. We conclude that bronchoscopy should be performed on all patients suspected of mycobacterial infection when sputum bacilloscopy is negative and patients have no expectoration. Performance of BAL should be routine since this simple and usually uncomplicated technique produces the most productive specimens.

Utility of bronchoalveolar lavage in assessing pneumonia in immunosuppressed renal transplant recipients

purpose: To determine if initial results obtained from diagnostic bronchoalveolar lavage (BAL) in immunosuppressed renal transplant patients with pulmonary infiltrates, fever, or hypoxemia can affect therapeutic decisions, morbidity, and mortality. design: A retrospective study of all BAL specimens obtained from renal transplant patients from January 1985 through June 1991. Initial results of Gram stain, cytology, cell differential count, and semi-quantitative bacterial cultures, all available within 24 hours of bronchoscopy, were compared with clinical outcomes and final diagnosis. setting: University hospital nephrology-transplant/pulmonary service. patients: Seventy renal transplant patients with a suspected pneumonia were stratified into 3 groups. A total of 48 patients underwent 58 bronchoscopies. Group 1 was comprised of 32 BALS that yielded 1 or more infectious organisms and was considered diagnostic. Group 2 (n = 26) were those BALs in which no organism was isolated and were thus nondiagnostic. Twenty-two additional immunosuppressed renal transplant recipients with pneumonia were considered by the admitting transplant nephrologist to have an uncomplicated community-acquired lung infection and thus were empirically treated and did not undergo BAL (Group 3). methods: BAL fluid analysis included cell differential count, cytopathologic examination, and culture for mycobacteria, legionella, fungi, viruses, and bacteria using a semi-quantitative technique. Etiologic diagnosis and the time of onset of the infectious processes were recorded. Therapeutic outcome and mortality were determined for each group. results: Thirty-nine etiologic organisms were found in 32 patients, with 6 patients having more than 1 infection. Twenty-two patients had 26 negative BALs, and 8 of these patients were clinically believed to have a volume overload state. Eight of 13 (61%) patients with bacterial pneumonia had BAL neutrophil counts greater than 20%, whereas 11 of 13 (84%) patients without bacterial pneumonia had neutrophil counts less than 20% (p <0.05). Those patients with an infectious etiology remained in the hospital longer than patients without a specific etiologic organism identified (p <0.02). Therapeutic decisions leading to the institution of specific antibiotics were more frequently made in patients with a diagnostic BAL (p <0.0001). An overall 3-month mortality (16%) was low compared with the historical rate (30%). conclusion: BAL is a useful procedure in the diagnosis of an infectious process in immunosuppressed renal transplant patients where initial results can alter therapy in more than 70% of cases.

Clinical usefulness and safety of bronchoalveolar lavage (BAL) in elderly patients

Little is known about the indications, safety and clinical usefulness of bronchoalveolar lavage (BAL) in elderly patients. In order to address these issues, we reviewed our last 200 consecutive BAL procedures, of which 23 (11.5%) were performed in patients older than 75 years (range 75–90, mean age 80.7 years, 13 men and 10 women). All procedures were well tolerated and no complications were observed. In 17 of the 23 patients (74%), BAL results were compatible with or diagnostic for infectious pneumonia (6 cases), idiopathic pulmonary fibrosis (5 cases), lung cancer (2 cases), hypereosinophilic syndrome (2 cases), chronic eosinophilic pneumonia (1 case) and lymphoma (1 case). In 6 of the 23 patients (26%), BAL yielded no specific diagnostic information. These data indicate that BAL is a safe procedure with a high diagnostic yield in an elderly population with pulmonary disease of unknown origin.

Bronchoalveolar Lavage in the Diagnosis of Peripheral, Primary Lung Cancer

Numerous case reports have shown the advantage of using bronchoalveolar lavage (BAL) in cytologic diagnosis of primary and secondary malignant neoplasms of the respiratory system. The aim of this study was to determine the usefulness of BAL in the diagnosis of peripheral, primary lung cancer. Of 1,864 patients referred to the Bronchological Department for endoscopic examination, 145 patients were studied: six with large cell lung cancer, 22 with adenocarcinoma, 15 with alveolar cell lung cancer, 40 with small cell lung cancer, and 62 with squamous cell lung cancer. In 94 patients (64.8 percent), BAL was diagnostic, revealing malignant cells. In 52 (35.9 percent) of these patients, the cytologic diagnosis agreed with the final pathologic diagnosis of the resected tumor. The result of BAL was affected by the type of cancer and size of the tumor. Highest yields were seen in adenocarcinoma (59.2 percent) and alveolar cell lung cancer (80 percent). The average size of the tumor in the group with correct cell typing was 4.9 +/- 1.8 cm; in patients with nondiagnostic BAL, the average size was 2.6 +/- 1.2 cm. BAL provided the highest (statistically significant, p less than 0.05) diagnostic yield (64.8 percent) in comparison with other sampling techniques: brush biopsy (29.8 percent), catheter biopsy (26.8 percent), and forceps biopsy (32.7 percent). The diagnostic yield of BAL and transbronchial fine needle aspiration biopsy (58.3 percent) did not significantly differ. BAL proved to be a valuable diagnostic tool in detecting peripheral, primary, pulmonary malignant neoplasms.

Bronchoalveolar lavage in patients with connective tissue disease.

Bronchoalveolar lavage (BAL) allows the recovery of cellular and fluid constituents that are derived from the epithelial surface of the lower respiratory tract. BAL fluid and cell analysis has become an important tool for understanding human pulmonary disease. Changes in the quantities and patterns of BAL cells and secretions have been described in a number of chronic lung disorders, especially the diffuse interstitial lung diseases. Specific BAL alterations have correlated with patient outcome and response to therapy. The connective tissue diseases have been associated with serious pleural and/or pulmonary pathology and may be a major cause of morbidity and mortality. BAL appears to be a useful semi-invasive tool in the evaluation and management of lung disease in patients with connective tissue diseases. The article describes the BAL findings in various connective tissue diseases and assesses the usefulness of BAL in the clinical management of patients with pulmonary complications.

Bronchoalveolar lavage in lung cancer.

The analysis of soluble and cellular components of bronchoalveolar lavage (BAL) fluids might help the diagnosis of a specific tumour. Up to now disease specific humoral constituents have not yet been found. Concerning cellular recovery, BAL can be useful particularly in patients with bronchiolo-alveolar carcinoma. The overall diagnostic yield in the case series presently available in the literature ranges from 35 to 69%. We evaluated the usefulness of BAL in the diagnosis of diffuse neoplastic lung lesions. The BAL provided a diagnostic yield in 75.9% of patients with biopsy or autopsy proven neoplasm, the sensitivity varying according to the type and growth pattern of the tumour (93% in bronchioloalveolar carcinoma). BAL can prove useful also in the diagnosis of pulmonary involvement in lymphoproliferative disorders, particularly when the immunologic evaluation of surface markers is performed. We conclude that in the appropriate setting BAL represents a useful tool for studying patients with lung cancer.

Sequential changes in lung injury induced by preformed immune complexes

Immune complexes formed in the airside may be involved in the early parenchymal changes in hypersensitivity pneumonitis. The present study was undertaken to compare the responses of animals after an intratracheal injection with preformed immune complexes to those of patients with acute hypersensitivity pneumonitis, with special emphasis on sequential bronchoalveolar lavage findings and the possible role of chemotactic factors in the immune complex-induced lung injury. An increased number and percentage of polymorphonuclear cells could be detected in bronchoalveolar lavage fluids of guinea pigs within 48 hr following an intratracheal injection of preformed immune complexes. Chemotactic factor activity preceded the observed increase of polymorphonuclear cells in bronchoalveolar lavage fluids, suggesting a role for chemotactic factors in the sequestration of these cells in the lung. In addition, this study confirmed the usefulness of bronchoalveolar lavage in evaluating the pulmonary findings because the changes in bronchoalveolar lavage cell populations correlated with sequential histological findings. The sequential characteristics of the involved areas were noted to be of a peribronchial or bronchiolar infiltration with polymorphonuclear cells at early stages, then alveolar sac infiltration, followed by mild infiltration of mononuclear cells into the alveolar walls. The findings suggest a possible role for chemotactic factors in the accumulation of polymorphonuclear cells, and the sequential changes of bronchoalveolar lavage and histological findings in animals are comparable to those in patients with acute hypersensitivity pneumonitis.

Phenotypic expression of bronchoalveolar lavage cells in lung rejection and infection

The differentiation of episodes of lung allograft rejection from infection continues to be a problem. Bronchoalveolar lavage (BAL) has recently gained some success in the diagnosis and management of interstitial lung disease. To assess the usefulness of BAL in differentiating between lung allograft rejection and infection, we examined the differences in cellular subsets of BAL and peripheral blood (PBL) samples in a controlled canine model of rejection or pneumonia. Single-lung allotransplants were allowed to undergo rejection by withdrawing immunosuppressive agents (n = 6). In another group of dogs (n = 5), pneumonia was induced by transbronchial injection of Pseudomonas aeruginosa and melted agar followed by bronchial fulguration. Cells obtained from bronchoscopic BAL and PBL samples were labeled with functionally characterized cross-reactive murine monoclonal antibodies. Transthoracic needle biopsies and transbronchial biopsies were done to assess their adequacy in examining the rejecting or infected lungs and were compared with open lung biopsies. We found the following: (1) the percentage of DT2-labeled cells was significantly higher (p < 0.05) in BAL samples from rejecting lungs compared with infected lungs; (2) the PBL/BAL ratio of DT2-labeled cell percentages was significantly higher in pneumonia (1.7 ± 0.3) than rejection (0.5 ± 0.2) (p < 0.004); (3) the percentage of E11-labeled cells in PBL samples was significantly higher (p < 0.02) in rejection than in infection; and (4) the ratio of WIG4 to DT2 cellular subset percentages in BAL samples from rejection (26.8 ± 9.9) was significantly lower than from infection (61.0 ± 22.9) (p < 0.03). Transthoracic and transbronchial biopsies did not always yield representative specimens. We conclude that differences in cellular subset composition in BAL and PBL samples from lung allotransplant rejection and pneumonia do occur. These changes may reflect the specific mechanisms of lung injury in rejection and in pneumonia. With further understanding of these changes, examination of PBL and BAL samples from lung transplant recipients will allow easier and safer differentiation of episodes of rejection from pneumonia.

The usefulness of bronchoalveolar lavage in identifying past occupational exposure to asbestos: a light and electron microscopy study.

Fiberoptic bronchoscopy has permitted the development of lavage procedures for the collection of lung washes. In certain disease states this material may contain large numbers of phagocytic cells (macrophages and neutrophils). Since these phagocytes are the predominant "dust scavenger cells" in the lung, the assessment of their particulate burden as well as that of the overall lavage material has been suggested as a potentially important diagnostic tool. The studies to date have shown that the presence of ferruginous bodies is an indication of past occupational exposure. In the present study, a digestion procedure was carried out on bronchoalveolar lavage material collected from individuals who were occupationally exposed to asbestos and from samples obtained from the general population. The parameters used for distinguishing the source of these samples included both light microscopy assessment of the filters for the presence of ferruginous bodies and electron microscopic screening for the presence of uncoated fibers.

Bronchoalveolar Lavage for Rapid Diagnosis of the Fat Embolism Syndrome in Trauma Patients

To evaluate the usefulness of bronchoalveolar lavage in establishing the diagnosis of the fat embolism syndrome in trauma patients with long-bone fractures. Case series. Referral hospital. Eighteen trauma patients with long-bone fractures, including 5 with definite fat embolism syndrome, 5 in whom the diagnosis had been clinically suspected but was impossible to confirm or exclude before bronchoscopy, and 8 with no clinical evidence of the syndrome. Control groups included 9 patients without previous trauma who developed the adult respiratory distress syndrome for various reasons and 15 normal volunteers. Each patient had fiber-optic bronchoscopy with bronchoalveolar lavage, and the percentage of lavage cells containing intracellular fat droplets stained with oil red 0 were determined. In the five patients with definite fat embolism syndrome, light microscopic study of bronchoalveolar cells stained with oil red 0 showed many large intracellular fat droplets (mean percentage of cells containing fat droplets, 63%; range, 31% to 82%), whereas less than 2% of cells recovered by lavage from trauma patients with no clinical evidence of the syndrome, from patients with the adult respiratory distress syndrome, or from normal volunteers contained such inclusions. Use of the same technique in the five patients with possible fat embolism syndrome permitted the immediate identification of three patients in whom this diagnosis was later confirmed by subsequent autopsy or clinical follow-up. The identification of fat droplets within cells recovered by bronchoalveolar lavage in trauma patients may be a rapid and specific method for establishing the diagnosis of the fat embolism syndrome.

Pulmonary Disease Progress in Sarcoid Patients with and without Bronchoalveolar Lavage Collagenase

To assess the usefulness of bronchoalveolar lavage (BAL) collagenase measurement in gauging disease severity and outcome in sarcoidosis, we analyzed BAL fluids from 84 patients with sarcoidosis for collagenase and monitored disease progress in these patients for a minimum of 12 months. Twenty patients (24%) were found to have BAL collagenase activity on initial evaluation (collagenase-positive group). Compared with patients without BAL collagenase (collagenase-negative group), the collagenase-positive group had (1) a higher proportion of BAL suppressor T cells (p less than 0.03); (2) a lower helper-suppressor T-cell ratio (p less than 0.002); (3) lower mean percent predicted FEV1, FVC, and DLCO levels (p less than 0.05); and (4) a higher proportion of patients with advanced (Stage 4) disease on chest roentgenogram (p less than 0.001). Significant differences were also observed between the collagenase-positive and collagenase-negative groups during follow-up. A higher proportion (55%, n = 11) of collagenase-positive patients required corticosteroid therapy than did collagenase-negative patients (26%; n = 17; p less than 0.025). Of those who remained untreated, pulmonary function tended to decrease in the collagenase-positive group, whereas mean pulmonary function levels actually improved in the collagenase negative group (p less than 0.05). Of those who required therapy, mean percent predicted FVC and DLCO levels improved significantly after treatment in the collagenase-negative group (p less than 0.01 and p less than 0.05, respectively), whereas an improvement in percent predicted FVC levels only (p less than 0.01) was observed in the collagenase-positive group.(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of bronchoalveolar lavage in the assessment of diffuse pulmonary infiltrates in nonAIDS immunocompromized patients

The efficacy of bronchoscopy with bronchoalveolar lavage for diagnosing 32 episodes of diffuse pulmonary infiltrates was studied in 30 nonAIDS immunocompromised patients. Bronchoalveolar lavage had an overall diagnostic yield of 84% (27 of 32 episodes). Bronchoalveolar lavage was noncontributive in five episodes of pneumonitis: drug induced in one, nonspecific in three and pneumonitis of unestablished etiology in one. Overall, the procedure is safe and did not miss diagnoses for which conventional treatment was available. Our data support the use of bronchoscopy with bronchoalveolar lavage as the primary diagnostic procedure in immunocompromised patients with diffuse pulmonary infiltrates.

Syndrome pneumo-rénal induit par la d-pénicillamine : Syndrome de Goodpasture ou polyartérite microscopique ?

Diffuse alveolar haemorrhage associated with glomerulonephritis is a rare but serious complication of d-penicillamine therapy. A case is reported which illustrates the usefulness of bronchoalveolar lavage and kidney needle biopsy for the early diagnosis of this condition. A search for antiglomerular basement membrane antibodies in serum was negative, whereas antigranulocyte cytoplasmic antibodies were present. These immunological results differentiated the disease from Goodpasture's syndrome to which it is clinically related and placed it in the same category as microscopic polyarteritis. After treatment with corticosteroids, cytostatic drugs and plasmapheresis, the outcome was favourable in contrast with the usually poor prognosis.

Clinical Utility of Bronchoalveolar Lavage in a General Hospital

Although bronchoalveolar lavage (BAL) performed through a fiberoptic bronchoscope is a valuable research tool, its clinical utility has been established in only two specific populations-the acquired immunodeficiency syndrome and immunosuppressed hosts with diffuse pulmonary infiltrates. We questioned whether BAL would be helpful in decision making in a general hospital setting. Eighteen patients, none of whom had the combination of immunosuppression and diffuse roentgenographic infiltrates and none of whom had acquired immunodeficiency syndrome, underwent BAL without any complications. The BAL fluid was analyzed in a hospital clinical laboratory using only stains that are generally used for bronchial washings. Retrospective analysis showed that in 9 cases (50%), the BAL analysis resulted in a significant alteration of therapy that would not have occurred using bronchial washings alone. Therefore, it appears that BAL can be safely performed in a general hospital on various patient populations, and that analysis in a nonresearch laboratory can yield clinically useful results.

Asbestosis occurring after brief inhalational exposure: usefulness of bronchoalveolar lavage in diagnosis.

A case of clinically and radiologically typical asbestosis manifesting in a 55 year old man occurred 36 years after a brief exposure period of less than one year. A transbronchial lung biopsy was performed but the samples were considered non-diagnostic. The diagnosis was supported by the use of bronchoalveolar lavage to obtain alveolar samples and scanning electron microscopy-energy dispersive x ray analysis of fibres found in the bronchoalveolar lavage fluid which showed a predominance of amosite.

Validity of bronchoalveolar lavage in acute lung injury: Recovered cells accurately reflect changes in the lung parenchyma

Bronchoalveolar lavage (BAL) has come into widespread use as a tool to diagnose and manage various lung diseases. However, the usefulness of BAL is based on the assumption that the cells recovered in BAL fluid accurately reflect cellular populations in the lung parenchyma. To test this hypothesis, random source (n = 16) dogs were given intravenous phorbol myristate acetate (PMA) to produce acute, diffuse lung inflammation. Dogs were divided into three groups. Group I animals (n = 2) underwent BAL and open lung biopsy at time zero. Group II (n = 7) animals underwent hourly BAL after PMA with open lung biopsy at 3 h. Group III (n = 7) animals underwent hourly BAL after PMA with open lung biopsy at 6 h. When BAL cell populations were compared with the corresponding biopsies, there was a direct correlation (r = 0.67) between BAL neutrophil percentages and neutrophils present in histologic sections. These findings suggest BAL accurately reflects changes in the lung parenchyma in acute lung disease.

Usefulness of Bronchoalveolar Lavage in Asthmatics

Bronchoalveolar lavage (BAL) has been studied in asthmatic patients; it is a well-tolerated procedure and can be used in clinical practice to evaluate individual patients. However, the main question is: Does BAL contribute to a better understanding of the pathophysiology of bronchial asthma? The arguments in favour are as follows: (1) experiments in monkeys, indicating that the cells recovered by BAL contribute to the triggering of asthma; (2) demonstration of inflammatory cell (eosinophils, neutrophils, and lymphocytes) influx after allergen inhalation challenge, and (3) in vitro demonstration of cellular activation corresponding with clinical symptoms. BAL offers a new approach to the understanding of asthma. There is a lot of unresolved questions which should encourage us to exploit its potential to the full.