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Broncho-Alveolar Broncho-Alveolar Lavage Lavage By By Lecturer: Riham Raafat Lecturer: Riham Raafat

Broncho-Alveolar Lavage

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Page 1: Broncho-Alveolar Lavage

Broncho-Broncho-Alveolar Lavage Alveolar Lavage

By By

Lecturer: Riham Lecturer: Riham RaafatRaafat

Page 2: Broncho-Alveolar Lavage

Introduction: BAL is performed with the FOB in a wedge position within the selected broncho-pulmonary segment.

The total instilled volume of normal saline should be from 100-200ml, repeated 3 to 5 times with 20ml saline each.

To obtain an adequate specimen 40-60 mL (usually 40-70% recovery of the total instillate) must be drawn back.

Page 3: Broncho-Alveolar Lavage

General indications:- Non-resolving pneumonia

- Diffuse lung infiltrates (interstitial and/or

alveolar)

- Suspected alveolar hemorrhage

- Quantitative cultures for VAP

- Infiltrates in an immunocompromised host

- Exclusion of diagnosable conditions by BAL

- Research

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Common tests/Analysis:Gross observation Pulmonary alveolar proteinosis Opaque or translucent brownish or sandy colored fluid, sediments out into two layers if left to sit Alveolar hemorrhage Sequentially more

hemorrhagic with each aliquot

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Cell count and differential Alveolar macrophages (Normal >80%) Dec. in sarcoidosis (to 55% or less) Neutrophils (Normal <3%): Nonspecific, but suggests active alveolitis Inc. in:

• IPF• ARDS• Infection• Connective tissue disorders• Wegener's granulomatosis• Pneumoconiosis

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Eosinophils (Normal <1-2%) Low to Moderate Eosinophilia (5-20%):

• Drug induced lung disease (e.g. minocycline, nitrofurantoin, penicillin)

• Infections (parasitic, mycobacterial, fungal)• Bronchial Asthma• Malignancies (infrequently) • Other interstitial pneumonias occasionally (BOOP

or COP, IPF/UIP, ILD associated with Connective tissue disorders, Sarcoidosis)

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Moderate to Marked Eosinophilia (>20%): • ABPA• Churg-Strauss syndrome• Acute eosinophilic pneumonia• Chronic eosinophilic pneumonia• Idiopathic hypereosinophilic syndrome

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Lymphocytes (Normal <15%) Elevated CD4/CD8: • Active sarcoidosis (>4:1 up to 10:1)• Berylliosis• Asbestosis• Crohn's disease• Connective tissue disorders• Sometimes in normal persons (inc. with age)

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Normal CD4/CD8 (0.9-2.5:1): • Tuberculosis• MalignanciesLow CD4/CD8: • Hypersensitivity Pneumonitis• Silicosis• Drug-induced lung disease• HIV infection• BOOP (COP)

Others: Lymphoma, Viral Pneumonia, Alveolar Proteinosis

Page 10: Broncho-Alveolar Lavage

Erythrocytes ◦ Elevated erythrocyte count - early sign of

alveolar hemorrhage (first several hours) ◦ Phagocytosed erythrocytes - alveolar

hemorrhage within 48 hrs ◦ Hemosiderin laden macrophages - alveolar

hemorrhage > 48hrs

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MicrobiologyCultures Stains and Immunohistochemistry

◦ Gram stain: Bacterial ◦ KOH preparation: Fungal ◦ Periodic acid-Schiff (PAS): Pulmonary alveolar proteinosis ◦ Auramine-rhodamine or Ziehl-Neelson: Mycobacterial ◦ Modified acid fast stain (Kinyoun): Nocardia ◦ Silver methenamine: Pneumocystis carinii pneumonia,

fungal ◦ Direct fluorescent antibody testing (DFA) for Legionella

Polymerase chain reaction (PCR) TB and othersQuantitative or semi-quantitative cultures VAP

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CytologyFoamy macrophages: Nonspecific: amiodarone useMalignancies

◦ Lymphangitic carcinomatosis ◦ Lymphoma ◦ Bronchoalveolar carcinoma and other primary lung◦ Extrapulmonary malignancies

Sulfur granules: Actinomycetes Hemosiderin Laden Macrophages: 20% is highly specific and

sensitive for alveolar hemorrhageLangerhans cells: >5% Pulmonary LCHCytomegalic cells: Viral pneumonias (CMV, herpes) Oil red O stain: in fat embolism Fat and Lipid stain (e.g. Sudan III):

◦ Lipid-laden alveolar macrophage index > 100 (Sensitivity of 100%, Specificity 57%)

◦ Lipoid pneumonia (aspiration)

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Complications/Adverse events:No complications in up to 95% Cough Transient fever (2.5%) Transient chills and myalgias Transient infiltrates in most (resolves in 24 hours) Bronchospasm (<1%) Transient fall of lung function Transient decrease in baseline PaO2 In patients with already severely compromised respiratory status, the loss of lung function may necessitate the need for MV.

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