Bronchoalveolar lavage explained

Bronchoalveolar lavage
Synonyms:Bronchoalveolar washing

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] (e.g. 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]

In particular, bronchoalveolar lavage is commonly used to diagnose infections in people with immune system problems,[12] pneumonia in people on ventilators, and acute respiratory distress syndrome (ARDS).[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.

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. 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.

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

Notes and References

  1. Diagnosing bacterial respiratory infection by bronchoalveolar lavage . Journal of Infectious Diseases . Kahn, F.W. . Jones, J.M. . 155 . 5 . 826–9 . 1987 . 10.1093/infdis/155.5.862 . 3559290.
  2. Book: https://books.google.com/books?id=co2CDwAAQBAJ&pg=PA50 . 6. Bronchoscopy in the Intensive Care Unit . Atlas of Critical Care Procedures . Sugeir, S. . de Moraes, A.G. . Demetriades, D.. Inaba, K. . Springer . 50 . 2019 . 9783319783673.
  3. Book: https://books.google.com/books?id=co2CDwAAQBAJ&pg=PA57 . 7. Bronchoalveolar Lavage . Atlas of Critical Care Procedures . Warriner, Z. . Lewis, M. . Demetriades, D.. Inaba, K. . Springer . 57–62 . 2019 . 9783319783673.
  4. The role of bronchoalveolar lavage in the diagnosis of bacterial pneumonia . European Journal of Clinical Microbiology and Infectious Diseases . Nieto, J.M.S. . Alcaraz, A.C. . 14 . 839–50 . 1995 . 10 . 10.1007/BF01691489 . 8605896. 7102128 .
  5. Bilateral versus unilateral bronchoalveolar lavage for the diagnosis of ventilator-associated pneumonia . Surgical Infections . Jonker, M.A. . Sauerhammer, T.M. . Faucher, L.D. . etal . 13 . 6 . 391–5 . 2012 . 10.1089/sur.2011.081 . 23240724 . 3532003.
  6. 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 . Yang, X.J. . Wang, Y.B. . Zhou, Z.W. . etal . 9 . 4883–96 . 2015 . 10.2147/DDDT.S87634 . 26345636 . 4554422 . free .
  7. 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 . World Health Organization . 19 March 2020 . 10665/331501 . 25 March 2020.
  8. Web site: 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 . Centers for Disease Control and Prevention . 25 March 2020 . 25 March 2020.
  9. An official American Thoracic Society clinical practice guideline: The clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease . American Journal of Respiratory and Critical Care Medicine . Meyer, K.C. . Raghu, G. . Baughman, R.P. . etal . 185 . 9 . 1004–14 . 2012 . 10.1164/rccm.201202-0320ST . 22550210 .
  10. Detection of SARS-CoV-2 by bronchoalveolar lavage after negative nasopharyngeal testing: Stay vigilant for COVID-19 . Respiratory Medicine Case Reports . Ramos KJ, Kapnadak SG, Collins BF, Wall R, Bryson-Cahn C, Perchetti GA, Jerome KR, Khot S, Limaye AP, Mathias PC, Greninger AL . Alexander L. Greninger. Keith R. Jerome. 101120 . 2020 . 30 . 10.1016/j.rmcr.2020.101120 . 32566476 . 7298516 . free .
  11. 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 . Rodrigo, D. . Rathnapala, A. . Senaratne, W. . 9 . 93 . 2015 . 10.1186/s13256-015-0574-z . 25925248 . 4421915 . free .
  12. Bronchoalveolar lavage . Archives of Disease in Childhood . Henderson, A.J. . 70 . 3 . 167–9 . 1994 . 10.1136/adc.70.3.167 . 8135556 . 1029733.
  13. Lung fluid biomarkers for acute respiratory distress syndrome: A systematic review and meta-analysis . Critical Care . Wang, Y. . Wang, H. . Zhang, C. . etal . 23 . 43 . 2019 . 1 . 10.1186/s13054-019-2336-6 . 30755248 . 6373030 . free .
  14. Analysis of curative effect of adjuvant therapy with bronchoalveolar lavage on COPD patients complicated with pneumonia . Experimental and Therapeutic Medicine . Zhao, H. . Gu, H. . Liu, T. . Ge, J. . Shi, G. . 16 . 5 . 3799–3804 . 2018 . 10.3892/etm.2018.6662 . 30344655 . 6176127.
  15. Wu . X . Lu . W . Wang . T . Xiao . A . Guo . X . Xu . Y . Li . S . Liu . X . Zeng . H . He . S . Zhang . X . Optimization strategy for the early timing of bronchoalveolar lavage treatment for children with severe mycoplasma pneumoniae pneumonia. . BMC Infectious Diseases . 5 October 2023 . 23 . 1 . 661 . 10.1186/s12879-023-08619-9 . 37798699 . 10557288 . free .
  16. Whole-lung lavage for pulmonary alveolar proteinosis . Chest . Michaud, G. . Reddy, C. . Ernst, A. . 136 . 6 . 1678–1681 . 2009 . 10.1378/chest.09-2295 . 19995769.
  17. Web site: How 'Lung Washing' Helps You Breathe Again . Cleveland Clinic . HealthEssentials . 6 August 2014 . 25 March 2020 . 14 August 2020 . https://web.archive.org/web/20200814074306/https://health.clevelandclinic.org/how-lung-washing-helps-patients-breathe-again-video/ . dead .
  18. Therapeutic applications of bronchoalveolar lavage . European Respiratory Journal . Danel, C. . Israël-Biet, D. . Costabel, U. . Klech, H. . 5 . 10 . 1173–5 . 1992 . 10.1183/09031936.93.05101173 . 1486961. 6265382 . free .
  19. Wang . Lijun . Xie . Qiuling . Xu . Shanshan . Li . Huajun . Zhang . Liya . Ai . Jingwen . Liu . Quanhua . Chu . Caiting . Zhang . Xi . Zhang . Wenhong . Huang . Lisu . The role of flexible bronchoscopy in children with Mycoplasma pneumoniae pneumonia . Pediatric Research . January 2023 . 93 . 1 . 198–206 . 10.1038/s41390-021-01874-z. 35459766 . 248326894 .

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