Bronchoalveolar lavage

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Bronchoalveolar lavage
Pronunciation /ˌbrɒŋkoʊˌælviˈoʊlərləˈvɑːʒ/ ⓘ BRONG-koh-AL-vee-OH-lər lə-VAHZH
Other namesBronchoalveolar washing
ICD-9-CM 33.24
MeSH D018893

Bronchoalveolar lavage (BAL), also known as bronchoalveolar washing, is a diagnostic method of the lower respiratory system in which a bronchoscope is passed through the mouth or nose into an appropriate airway in the lungs, with a measured amount of fluid introduced and then collected for examination. This method is typically performed to diagnose pathogenic infections of the lower respiratory airways [1] [2] [3] (leading to, for example pneumonia [4] [5] [6] and COVID-19 [7] [8] ), though it also has been shown to have utility in diagnosing interstitial lung disease. [9] Bronchoalveolar lavage can be a more sensitive method of detection than nasal swabs in respiratory molecular diagnostics, as has been the case with SARS-CoV-2 where bronchoalveolar lavage samples detect copies of viral RNA after negative nasal swab testing. [10] [11]

Contents

In particular, bronchoalveolar lavage is commonly used to diagnose infections in people with immune system problems, [12] pneumonia in people on ventilators, [5] [6] and acute respiratory distress syndrome (ARDS). [3] [13] It is the most common method used to sample the epithelial lining fluid (ELF) and to determine the protein composition of the pulmonary airways. [3] [13]

BAL has even been used therapeutically to remove mucus (sputum), improve airway ventilation, and reduce airway inflammation in conditions such as chronic obstructive pulmonary disease (COPD) [14] and pediatric Mycoplasma pneumonia. [15] A much more intense version involving up to 50 liters of fluid is called whole lung lavage (WLL) and is used to treat pulmonary alveolar proteinosis (PAP). [16] [17] [18] When conditions disallow WLL, an endoscopic BAL can be used as a bridging procedure. [11]

Equipment and procedure

The primary equipment used in BAL includes a fiber-optic bronchoscope, sterile collection traps for collecting test specimens, a sterile saline source, a suction device, and suction tubing. [3] Essentially, the saline source is connected to sterile bronchoscope, as is the specimen collection trap, and then suction tubing is connected to the trap and the suction source. If the bronchoscope is not sterile, saline should initially be used to flush it clean. With the patient under some sort of anesthesia (depending on the rigidity of the scope), the fiber-optic cable is lowered into the correct area of the lower lungs (tracheobronchial tree), wedged into place, and saline applied. Once the saline is fully applied, then either suction is applied to collect the fluids, or the fluids are collected with a sterile syringe through the irrigation channel. The collection trap is then appropriately labeled and sent off for testing. [3]

Recent literature for the use of endoscopic BAL in therapy uses essentially the same process. A flexible bronchoscope is most commonly used. The physician seeks out areas with excess mucus or other abnormalities, then uses saline and suction to clean it. [19] [14]

See also

Related Research Articles

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A sputum culture is a test to detect and identify bacteria or fungi that infect the lungs or breathing passages. Sputum is a thick fluid produced in the lungs and in the adjacent airways. Normally, fresh morning sample is preferred for the bacteriological examination of sputum. A sample of sputum is collected in a sterile, wide-mouthed, dry, leak-proof and break-resistant plastic-container and sent to the laboratory for testing. Sampling may be performed by sputum being expectorated, induced, or taken via an endotracheal tube with a protected specimen brush in an intensive care setting. For selected organisms such as Cytomegalovirus or "Pneumocystis jiroveci" in specific clinical settings a bronchoalveolar lavage might be taken by an experienced pneumologist. If no bacteria or fungi grow, the culture is negative. If organisms that can cause the infection grow, the culture is positive. The type of bacterium or fungus is identified by microscopy, colony morphology and biochemical tests of bacterial growth.

<span class="mw-page-title-main">Alveolar lung disease</span> Medical condition

Alveolar lung diseases, are a group of diseases that mainly affect the alveoli of the lungs.

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<span class="mw-page-title-main">Bronchoscopy</span> Procedure allowing a physician to look at a patients airways

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<span class="mw-page-title-main">Lipid-laden alveolar macrophage</span> Pathological cells in lung

Lipid-laden alveolar macrophages, also known as pulmonary foam cells, are cells found in bronchoalveolar lavage (BAL) specimens that consist of macrophages containing deposits of lipids (fats). The lipid content of the macrophages can be demonstrated using a lipid targeting stain like Oil Red O or Nile red. Increased levels of lipid-laden alveolar macrophages are associated with various respiratory conditions, including chronic smoking, gastroesophageal reflux, lipoid pneumonia, fat embolism, pulmonary alveolar proteinosis and pulmonary aspiration. Lipid-laden alveolar macrophages have been reported in cases of vaping-associated pulmonary injury.

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Whole lung lavage (WLL), also called lung washing, is a medical procedure in which the patient's lungs are washed with saline by filling and draining repeatedly. It is used to treat pulmonary alveolar proteinosis, in which excess lung surfactant proteins prevent the patient from breathing. Some sources consider it a variation of bronchoalveolar lavage.

References

  1. ↑ Kahn, F.W.; Jones, J.M. (1987). "Diagnosing bacterial respiratory infection by bronchoalveolar lavage". Journal of Infectious Diseases. 155 (5): 826–9. doi:10.1093/infdis/155.5.862. PMID   3559290.
  2. ↑ Sugeir, S.; de Moraes, A.G. (2019). "6. Bronchoscopy in the Intensive Care Unit". In Demetriades, D.; Inaba, K. (eds.). Atlas of Critical Care Procedures. Springer. p. 50. ISBN   9783319783673.
  3. 1 2 3 4 5 Warriner, Z.; Lewis, M. (2019). "7. Bronchoalveolar Lavage". In Demetriades, D.; Inaba, K. (eds.). Atlas of Critical Care Procedures. Springer. pp. 57–62. ISBN   9783319783673.
  4. ↑ Nieto, J.M.S.; Alcaraz, A.C. (1995). "The role of bronchoalveolar lavage in the diagnosis of bacterial pneumonia". European Journal of Clinical Microbiology and Infectious Diseases. 14 (10): 839–50. doi:10.1007/BF01691489. PMC   7102128 . PMID   8605896.
  5. 1 2 Jonker, M.A.; Sauerhammer, T.M.; Faucher, L.D.; et al. (2012). "Bilateral versus unilateral bronchoalveolar lavage for the diagnosis of ventilator-associated pneumonia". Surgical Infections. 13 (6): 391–5. doi:10.1089/sur.2011.081. PMC   3532003 . PMID   23240724.
  6. 1 2 Yang, X.J.; Wang, Y.B.; Zhou, Z.W.; et al. (2015). "High-throughput sequencing of 16S rDNA amplicons characterizes bacterial composition in bronchoalveolar lavage fluid in patients with ventilator-associated pneumonia". Drug Design, Development and Therapy. 9: 4883–96. doi: 10.2147/DDDT.S87634 . PMC   4554422 . PMID   26345636.
  7. ↑ World Health Organization (19 March 2020). "Laboratory testing for coronavirus disease (COVID-19) in suspected human cases: Interim guidance, 19 March 2020". WHO/COVID-19/Laboratory/2020.5. World Health Organization. hdl:10665/331501 . Retrieved 25 March 2020.
  8. ↑ Centers for Disease Control and Prevention (25 March 2020). "Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19)". Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. Retrieved 25 March 2020.
  9. ↑ Meyer, K.C.; Raghu, G.; Baughman, R.P.; et al. (2012). "An official American Thoracic Society clinical practice guideline: The clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease" (PDF). American Journal of Respiratory and Critical Care Medicine. 185 (9): 1004–14. doi:10.1164/rccm.201202-0320ST. PMID   22550210.
  10. ↑ Ramos KJ, Kapnadak SG, Collins BF, Wall R, Bryson-Cahn C, Perchetti GA, Jerome KR, Khot S, Limaye AP, Mathias PC, Greninger AL (2020). "Detection of SARS-CoV-2 by bronchoalveolar lavage after negative nasopharyngeal testing: Stay vigilant for COVID-19". Respiratory Medicine Case Reports. 30: 101120. doi: 10.1016/j.rmcr.2020.101120 . PMC   7298516 . PMID   32566476.
  11. 1 2 Rodrigo, D.; Rathnapala, A.; Senaratne, W. (2015). "Therapeutic limited bronchoalveolar lavage with fiberoptic bronchoscopy as a bridging procedure prior to total lung lavage in a patient with pulmonary alveolar proteinosis: A case report". Journal of Medical Case Reports. 9. 93. doi: 10.1186/s13256-015-0574-z . PMC   4421915 . PMID   25925248.
  12. ↑ Henderson, A.J. (1994). "Bronchoalveolar lavage". Archives of Disease in Childhood. 70 (3): 167–9. doi:10.1136/adc.70.3.167. PMC   1029733 . PMID   8135556.
  13. 1 2 Wang, Y.; Wang, H.; Zhang, C.; et al. (2019). "Lung fluid biomarkers for acute respiratory distress syndrome: A systematic review and meta-analysis". Critical Care. 23 (1). 43. doi: 10.1186/s13054-019-2336-6 . PMC   6373030 . PMID   30755248.
  14. 1 2 Zhao, H.; Gu, H.; Liu, T.; Ge, J.; Shi, G. (2018). "Analysis of curative effect of adjuvant therapy with bronchoalveolar lavage on COPD patients complicated with pneumonia". Experimental and Therapeutic Medicine. 16 (5): 3799–3804. doi:10.3892/etm.2018.6662. PMC   6176127 . PMID   30344655.
  15. ↑ Wu, X; Lu, W; Wang, T; Xiao, A; Guo, X; Xu, Y; Li, S; Liu, X; Zeng, H; He, S; Zhang, X (5 October 2023). "Optimization strategy for the early timing of bronchoalveolar lavage treatment for children with severe mycoplasma pneumoniae pneumonia". BMC Infectious Diseases. 23 (1): 661. doi: 10.1186/s12879-023-08619-9 . PMC   10557288 . PMID   37798699.
  16. ↑ Michaud, G.; Reddy, C.; Ernst, A. (2009). "Whole-lung lavage for pulmonary alveolar proteinosis". Chest. 136 (6): 1678–1681. doi:10.1378/chest.09-2295. PMID   19995769.
  17. ↑ Cleveland Clinic (6 August 2014). "How 'Lung Washing' Helps You Breathe Again". HealthEssentials. Archived from the original on 14 August 2020. Retrieved 25 March 2020.
  18. ↑ Danel, C.; Israël-Biet, D.; Costabel, U.; Klech, H. (1992). "Therapeutic applications of bronchoalveolar lavage". European Respiratory Journal. 5 (10): 1173–5. doi: 10.1183/09031936.93.05101173 . PMID   1486961. S2CID   6265382.
  19. ↑ Wang, Lijun; Xie, Qiuling; Xu, Shanshan; Li, Huajun; Zhang, Liya; Ai, Jingwen; Liu, Quanhua; Chu, Caiting; Zhang, Xi; Zhang, Wenhong; Huang, Lisu (January 2023). "The role of flexible bronchoscopy in children with Mycoplasma pneumoniae pneumonia". Pediatric Research. 93 (1): 198–206. doi:10.1038/s41390-021-01874-z. PMID   35459766. S2CID   248326894.
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