BIBI 11

Part 2A: Bronchioloalveolar lavage, Part 2A: Bronchioloalveolar lavage, volume 1volume 1

Bronchoscopy InternationalBronchoscopy International

Strategy and Planning

Execution

BIBI 22

HistoryHistory

BALBAL Originally described in the 1970sOriginally described in the 1970s Originally referred to as a “Originally referred to as a “Liquid lung Liquid lung

biopsy”biopsy” A BAL samples the contents of millions of alveoliA BAL samples the contents of millions of alveoli

Yield is therefore greatest for alveolar filling processesYield is therefore greatest for alveolar filling processes

This is NOT a bronchial wash !

BIBI 33

BAL todayBAL today

Performed routinely in patients with pulmonary Performed routinely in patients with pulmonary infiltrates of presumed infectious etiology.infiltrates of presumed infectious etiology.

Performed also in patients with history or Performed also in patients with history or suspicion of neoplasm.suspicion of neoplasm.

Performed for other alveolar filling processesPerformed for other alveolar filling processes Alveolar proteinosisAlveolar proteinosis Alveolar hemorrhageAlveolar hemorrhage Fat embolism and lipoid pneumoniaFat embolism and lipoid pneumonia

BIBI 44

Training is essential in order toTraining is essential in order to

Learn proper techniques and indicationsLearn proper techniques and indications Avoid procedure-related complications.Avoid procedure-related complications. Learn to protect the equipment and the Learn to protect the equipment and the

patientpatient To maximize fluid returnTo maximize fluid return To avoid scope-related traumaTo avoid scope-related trauma To avoid excess patient discomfort To avoid excess patient discomfort

(cough, anxiety, shortness of breath)(cough, anxiety, shortness of breath)..

BIBI 55

Greatest yield for BAL in patients withGreatest yield for BAL in patients with

Peripheral MalignancyPeripheral Malignancy Infection (Pneumocystis in HIV 96-98%)Infection (Pneumocystis in HIV 96-98%) Alveolar proteinosis, alveolar hemorrhageAlveolar proteinosis, alveolar hemorrhage Fat embolism and Lipoid pneumoniaFat embolism and Lipoid pneumonia Silicosis/berylliosis/asbestosSilicosis/berylliosis/asbestos Eosinophilic lung diseaseEosinophilic lung disease

BIBI 66

Indications for BALIndications for BAL Research applicationsResearch applications

Characteristic cellular patterns in numerous Characteristic cellular patterns in numerous diseases (asthma, ARDS)diseases (asthma, ARDS)

Several ILD have distinct findings on BAL Several ILD have distinct findings on BAL Well-defined cellular patterns for smokers, Well-defined cellular patterns for smokers,

former smokers, and nonsmokersformer smokers, and nonsmokers

BIBI 77

Contraindications to BALContraindications to BAL

No contraindications, butNo contraindications, but BAL-induced hypoxemia may last several BAL-induced hypoxemia may last several

hourshours And may exacerbate respiratory And may exacerbate respiratory

insufficiencyinsufficiency Caution also in ventilated patients (minimize Caution also in ventilated patients (minimize

time in the airway)time in the airway) In unstable patients with severe hypoxemia, In unstable patients with severe hypoxemia,

large volume BAL may be enough to prompt large volume BAL may be enough to prompt need for intubation.need for intubation.

BIBI 88

BAL Techniques varyBAL Techniques vary Location should be recorded in procedure Location should be recorded in procedure

notenote Increased yield in gravity dependent areasIncreased yield in gravity dependent areas Target involved segment in focal diseaseTarget involved segment in focal disease RML and lingula are also preferred sitesRML and lingula are also preferred sites

Wedge the scope in the target segment Wedge the scope in the target segment Suction channel should be in the airway lumen, Suction channel should be in the airway lumen,

not against the wallnot against the wall Confirmed by slight airway wall collapse with Confirmed by slight airway wall collapse with

gentle suctiongentle suction Fluid instillation gently dilates segmental Fluid instillation gently dilates segmental

airwayairway

BIBI 99

Bronchoalveolar lavageBronchoalveolar lavageBronchioloalveolar lavageBronchioloalveolar lavage

Video of BAL Example

BIBI 1010

BAL techniqueBAL technique Saline instillation (room temperature)Saline instillation (room temperature)

Small aliquots (20-60 each) via syringeSmall aliquots (20-60 each) via syringe More than 100 cc total per segment More than 100 cc total per segment

sampledsampled Usually done after biopsy or brushing to Usually done after biopsy or brushing to

increase cellular content of BAL sample for increase cellular content of BAL sample for diagnosis of infection or malignancydiagnosis of infection or malignancy

In ILD, changes in cell population of In ILD, changes in cell population of recovered fluid occurred only after at least recovered fluid occurred only after at least 120 cc is instilled.120 cc is instilled.

Am Rev Respir Dis 1985;132:390-392Am Rev Respir Dis 1982;126:611-616

BIBI 1111

Example of gravity bag technique for Example of gravity bag technique for BALBAL

Saline solution is hung, and bag is squeezed to gently deliver saline into target segment

BIBI 1212

BAL TechniquesBAL Techniques

Fluid recovery via suction channelFluid recovery via suction channel Hand suction into syringe, Gravity flow into a Hand suction into syringe, Gravity flow into a

dependent container, or Gentle wall suction into a dependent container, or Gentle wall suction into a specimen containerspecimen container

Optimal dwell time unknownOptimal dwell time unknown Some use slow deep inspiration with instillation Some use slow deep inspiration with instillation

and slow exhalation with recoveryand slow exhalation with recovery Recovery better with larger instilled volumesRecovery better with larger instilled volumes

First aliquot often recover < 20% of volumeFirst aliquot often recover < 20% of volume Subsequent aliquots recover 40-70% of volumeSubsequent aliquots recover 40-70% of volume Aliquots are usually pooled together often Aliquots are usually pooled together often

excluding the first aliquot (may contain mostly excluding the first aliquot (may contain mostly bronchial cells)bronchial cells)

BIBI 1313

Q9: Bronchoalveolar Lavage Fluid Q9: Bronchoalveolar Lavage Fluid return is usually greatest in smokers return is usually greatest in smokers

BIBI 1414

FALSEFALSE. In smokers, BAL fluid return is less . In smokers, BAL fluid return is less than in nonsmokers (in whom one might than in nonsmokers (in whom one might

expect to retrieve about 40-60 percent of the expect to retrieve about 40-60 percent of the fluid instilled). fluid instilled).

Techniques that help maximize fluid Techniques that help maximize fluid return includereturn include Instructing the patient to breathe deeply Instructing the patient to breathe deeply

during fluid instillation and during during fluid instillation and during suctioningsuctioning

Wedging the bronchoscope deep inside Wedging the bronchoscope deep inside the segmental bronchusthe segmental bronchus

Using suction pressures less than 120 cm Using suction pressures less than 120 cm HH22O (using manual suction rather than O (using manual suction rather than wall suction for example)wall suction for example)

BIBI 1515

BAL fluid return is also enhanced BAL fluid return is also enhanced byby

Targeting the middle Targeting the middle lobe or the lingula in lobe or the lingula in case of diffuse case of diffuse diseasedisease

Preferential selection Preferential selection of nondependent of nondependent abnormal areas in abnormal areas in case of localized case of localized diseasedisease

BAL fluid return video

BIBI 1616

Diagnostic yield for BALDiagnostic yield for BAL Characteristic cellular patterns in numerous Characteristic cellular patterns in numerous

diseasesdiseases Several ILD have distinct findings on BAL Several ILD have distinct findings on BAL Well-defined cellular patterns for smokers, former Well-defined cellular patterns for smokers, former

smokers, and nonsmokerssmokers, and nonsmokers More specific yields in:More specific yields in:

MalignancyMalignancy Infection (Pneumocystis in HIV 96-98%)Infection (Pneumocystis in HIV 96-98%) HemorrhageHemorrhage Alveolar proteinosisAlveolar proteinosis Fat embolismFat embolism Lipoid pneumoniaLipoid pneumonia Silicosis/berylliosis/asbestosSilicosis/berylliosis/asbestos Eosinophilic lung diseaseEosinophilic lung disease OthersOthers

BIBI 1717

Q9: Bronchoscopy with BAL is superior Q9: Bronchoscopy with BAL is superior to sputum induction to rule out to sputum induction to rule out

TuberculosisTuberculosis

BIBI 1818

FALSEFALSE. Induced sputum is equivalent to . Induced sputum is equivalent to bronchoscopy with BAL for routine evaluation bronchoscopy with BAL for routine evaluation

of suspected TB. of suspected TB. Anderson et alAnderson et al

Patients unable to expectorate or sputum negative. 3% saline Patients unable to expectorate or sputum negative. 3% saline followed by bronchoscopy. 26 had TB, 20 cases positive on followed by bronchoscopy. 26 had TB, 20 cases positive on sputum, 19 cases positive on bronchoscopy. Sensitivity: 73% sputum, 19 cases positive on bronchoscopy. Sensitivity: 73% bronchoscopy, 77% sputum. bronchoscopy, 77% sputum.

Conde et alConde et al 143 patients with confirmed TB. Diagnosis based on Single 143 patients with confirmed TB. Diagnosis based on Single

sputum induction in 66%, BAL 72%. This was Regardless of HIV sputum induction in 66%, BAL 72%. This was Regardless of HIV status. status.

Saglam et alSaglam et al HIV negative patients with suspected TB. Initially smear negative. HIV negative patients with suspected TB. Initially smear negative.

Sputum induction smear positive 47%, culture positive 63%. Sputum induction smear positive 47%, culture positive 63%. Bronchoscopy smear positive in 53% and culture positive in 67%. Bronchoscopy smear positive in 53% and culture positive in 67%.

McWilliams et alMcWilliams et al Prospective study. Patients initially smear negative, 3 sputum Prospective study. Patients initially smear negative, 3 sputum

inductions, if negative then bronchoscopy with BAL. 42 cases of inductions, if negative then bronchoscopy with BAL. 42 cases of TB. 27 TB patients went through all phases. 96% were positive on TB. 27 TB patients went through all phases. 96% were positive on induced sputum. 52% positive on bronchoscopy with BAL. Only 1 induced sputum. 52% positive on bronchoscopy with BAL. Only 1 positive using bronchoscopy alone. 13 positive with sputum positive using bronchoscopy alone. 13 positive with sputum induction alone and 13 were positive using both modalities. induction alone and 13 were positive using both modalities.

BIBI 1919

Induced sputum versus BAL Induced sputum versus BAL for detection of Acid Fast for detection of Acid Fast

Bacilli SmearBacilli Smear

AFB (shown in red) are tubercle bacilli

BIBI 2020

Induced Sputum vs BALInduced Sputum vs BAL

*Induced sputum vs BAL*Induced sputum vs BAL sensitivity 34% vs 38% sensitivity 34% vs 38% specificity 100% vs 100%specificity 100% vs 100% positive predictive value 100% vs 100%positive predictive value 100% vs 100% negative predictive value 53% vs 55%negative predictive value 53% vs 55%

These patients were able to participate in sputum These patients were able to participate in sputum induction.induction.

Multiple (up to 3) induced sputum samples should be Multiple (up to 3) induced sputum samples should be obtainedobtained

*Conde MB; Soares SL; Mello FC. Comparison of sputum induction with fiberoptic bronchoscopy in the diagnosis of tuberculosis: experience at an acquired immune deficiency syndrome reference center in Rio de Janeiro, Brazil; Am J Respir Crit Care Med 2000 Dec;162(6):2238-40.

BIBI 2121

Induced Sputum vs BALInduced Sputum vs BAL

Bronchoscopy should only be done after Bronchoscopy should only be done after induced sputum x 3 are negative, or in induced sputum x 3 are negative, or in patients unable to provide inducible sputum:patients unable to provide inducible sputum: Risks to pt/staff Risks to pt/staff limited availability of bronchoscopy in developing limited availability of bronchoscopy in developing

countriescountries

Michael Brown, Hansa Varia, Paul Bassett, Robert N. Davidson, Robert Wall and Geoffrey Pasvol. Prospective study of sputum induction, gastric washing, and bronchoalveolar lavage for the diagnosis of pulmonary tuberculosis in patients who are unable to expectorate. Clin Infect Dis. 2007 Jun 1;44(11):1415-20

BIBI 2222

BAL in Lung CancerBAL in Lung Cancer

BAL: performed in setting of peripheral, BAL: performed in setting of peripheral, endoscopically nonvisible lesionsendoscopically nonvisible lesions Cytology positive in about 25% with peripheral Cytology positive in about 25% with peripheral

lesionslesions Increases to 70% in patients with Increases to 70% in patients with

endoscopically visible lesionsendoscopically visible lesions Higher yield with infiltrates as opposed to Higher yield with infiltrates as opposed to

nodulesnodules Bronchoalveolar cell carcinoma: most readily Bronchoalveolar cell carcinoma: most readily

identified primary lung canceridentified primary lung cancer Positive cytology approaching 90%Positive cytology approaching 90%

Can also detect metastatic malignancyCan also detect metastatic malignancy Melanoma, soft tissue sarcoma, and Melanoma, soft tissue sarcoma, and

malignancies of breast, GI, and pancreas.malignancies of breast, GI, and pancreas.

BIBI 2323

BAL in immuno-suppressed patientsBAL in immuno-suppressed patients

DiagnostiDiagnostic c

YieldYield

HIVHIV Stem cell Stem cell transplantstransplantsChemotherapChemotherap

yy

Solid Solid organ organ

TransplantTransplantss

Other Other ss

TotalTotal

Bacteria Bacteria 202 202 (48%)(48%)

74 (20%)74 (20%) 45 (26%)45 (26%) 37 (37%)37 (37%) 358 358 (34%)(34%)

MycobacterMycobacteriaia

63 (15%)63 (15%) 0 0 0 (0%)0 (0%) 1 (1%)1 (1%) 64 64 (6%)(6%)

AspergillusAspergillus 1 (0.2%)1 (0.2%) 10 (3%)10 (3%) 6 (4%)6 (4%) 3 (3%)3 (3%) 20 20 (2%)(2%)

CMVCMV 119 119 (28%)(28%)

45 (12%)45 (12%) 46 (27%)46 (27%) 23 (23%)23 (23%) 233 233 (22%)(22%)

Other Other viruses viruses

37 (9%)37 (9%) 16 (4%)16 (4%) 23 (13%)23 (13%) 7 (7%)7 (7%) 83 83 (8%)(8%)

PCPPCP 110 110 (26%)(26%)

13 (4%)13 (4%) 25 (15%)25 (15%) 8 (8%)8 (8%) 156 156 (15%)(15%)

Total BALTotal BAL 420420 374374 173173 9999 10661066

Joos L et al. Pulmonary infections diagnosed by BAL: A 12-year experience in 1066 immunocompromised patients. Respir Med. 2006

BIBI 2424

BAL – related complications BAL – related complications and adverse eventsand adverse events

HypoxemiaHypoxemia Fever in 25-50 %Fever in 25-50 %

Usually resolves in a few hours and after Usually resolves in a few hours and after administration of antipyretics.administration of antipyretics.

Increased density on chest radiograph or CTIncreased density on chest radiograph or CT Crackles and alveolar infiltrates may last up to Crackles and alveolar infiltrates may last up to

24 hours24 hours Decrease in spirometryDecrease in spirometry PneumothoraxPneumothorax Increased mean airway pressures (in ventilated Increased mean airway pressures (in ventilated

patients)patients)

BIBI 2525

Other complications of BALOther complications of BAL BAL specific bleeding 0.7%BAL specific bleeding 0.7%11

Complication rates similar to those of Complication rates similar to those of inspection flexible bronchoscopyinspection flexible bronchoscopy

Mortality 0.01 -0.04%Mortality 0.01 -0.04% Major complications < 1%Major complications < 1% Fever, bleeding, infection, arrhythmia, respiratory Fever, bleeding, infection, arrhythmia, respiratory

depression, vagal reactions, pneumothorax, depression, vagal reactions, pneumothorax, bronchospasm, bacteremiabronchospasm, bacteremia

Decrease in pa02 is common and worse when Decrease in pa02 is common and worse when larger BAL volumes are used.larger BAL volumes are used.

Small series of critically ill pneumonia patients Small series of critically ill pneumonia patients experienced high fever with decreased MAP experienced high fever with decreased MAP and pa02and pa02**

1CHEST 1981;80:268-271 BAL in ILD *Intensive Care Med 1992;18:6

BIBI 2626

Safety of BALSafety of BAL

Can usually be done safely in Can usually be done safely in patients with asthmapatients with asthma

Numerous older studies showing Numerous older studies showing safety in AIDS, ARDS, mechanical safety in AIDS, ARDS, mechanical ventilation, thrombocytopenia.ventilation, thrombocytopenia.

BIBI 2727

Helpful Hints for performing Helpful Hints for performing BALBAL

Avoid rapid “trumpet playing”Avoid rapid “trumpet playing” Instead, suction gently and slowlyInstead, suction gently and slowly Keep scope in the midline Keep scope in the midline Avoid coughAvoid cough

Decreased recovery inDecreased recovery in COPD (correlates with worsening FEV1/FVC)COPD (correlates with worsening FEV1/FVC) Advanced age, smokers versus nonsmokersAdvanced age, smokers versus nonsmokers Mechanical ventilationMechanical ventilation When scope is over-wedgedWhen scope is over-wedged

Acknowledge an inadequate sampleAcknowledge an inadequate sample Less than 10% of instilled volumeLess than 10% of instilled volume Greater than 2% columnar epithelial cellsGreater than 2% columnar epithelial cells

Am Rev Respir Dis 1985;132:254-260

Good wedge where airway remains visible

BIBI 2828

More helpful hints for performing More helpful hints for performing BALBAL

Ask the patient to inhale, and even to hold Ask the patient to inhale, and even to hold one’s breath during fluid instillation.one’s breath during fluid instillation.

Use conscious sedation to improve patient Use conscious sedation to improve patient comfort.comfort.

Carefully examine airway-computed Carefully examine airway-computed tomography correlations to plan the procedure.tomography correlations to plan the procedure.

Inform bronchoscopy assistants of procedure Inform bronchoscopy assistants of procedure plan.plan.

Use instructions such as “traps on”, “traps Use instructions such as “traps on”, “traps off” , to communicate about when to retrieve off” , to communicate about when to retrieve BAL specimen and communicate with BAL specimen and communicate with assistants.assistants.

Inform cytologist and microbiologists of Inform cytologist and microbiologists of indications for the procedure.indications for the procedure.

BIBI 2929

This presentation is part of a This presentation is part of a comprehensive curriculum for comprehensive curriculum for

Flexible Bronchoscopy. Our Flexible Bronchoscopy. Our goals are to help health care goals are to help health care

workers become better at what workers become better at what they do, and to decrease the they do, and to decrease the burden of procedure-related burden of procedure-related

training on patients.training on patients.

BIBI 3030

BRONCHATLAS©

Step by Step©

Bronchoscopy.org

BIBI 3131

All efforts are made by Bronchoscopy All efforts are made by Bronchoscopy International to maintain currency of online International to maintain currency of online information. All published multimedia slide information. All published multimedia slide

shows, streaming videos, and essays can be shows, streaming videos, and essays can be cited for reference as:cited for reference as:

Bronchoscopy International: Art of Bronchoscopy, an Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published 2007 (Please add “Date Accessed”).Published 2007 (Please add “Date Accessed”).

Thank you

BIBI 3232

Prepared with the expert assistance of Udaya Prepared with the expert assistance of Udaya Prakash M.D. (Mayo Clinic, USA), and Atul Mehta Prakash M.D. (Mayo Clinic, USA), and Atul Mehta M.D. (Cleveland Clinic, USA), and Wes Shepherd M.D. (Cleveland Clinic, USA), and Wes Shepherd M.D. (Virginia Commonwealth University, USA)M.D. (Virginia Commonwealth University, USA)

www.bronchoscopy.org