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Bal fluid analysis


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Bal fluid analysis

  1. 1. Broncho-AlveolarBroncho-Alveolar Lavage Fluid AnalysisLavage Fluid Analysis By Dr Uttam Kumar DasBy Dr Uttam Kumar Das PGT Dept of Pathology BSMC Bankura 05.03.2014
  2. 2. 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 100-300ml, repeated 2 to 6 times with 20-50ml saline each. To obtain an adequate specimen 40-60 mL (usually 40-70% recovery of the total instillate) must be drawn back. Aspirates and washings provide information on the status of the respiratory tract in small bronchi beyond reach of the bronchoscopic brush.
  3. 3. Area That Is Lavaged  Procedures were usually performed in the right middle lobe or lingula  But lavage can be done in the most affected areas of the lung (In evaluating BAL in patients with Pneumocystis jirovecii pneumonia, it was found that lavage in the upper lobes had a higher yield than the traditional right middle lobe or lingula)
  4. 4. Handling of Aspirated Fluid  At the time of the lavage cells should be stored in silicone-coated or similar containers  Cell counts should probably be made on unfiltered, unwashed, and unconcentrated samples (If concentration is performed, the method should be specified)
  5. 5.  Centrifugation to concentrate proteins and cells can lead to loss of cells  Washing the cells can change the differential count considerably
  6. 6. Satisfactory Sample 1. A total of 2×106 cells is considered a minimum requirement 2. Furthermore, more than 10 macrophages should be present in a high-powered microscopic field 3. Degenerative changes should cover less than 20% of the specimen area on the slide 4. If the number of squamous epithelial cells, bronchial cells, RBCs, or inflammatory cells exceeds that of macrophages, the specimen is considered unsatisfactory
  7. 7. The Storage of Fluid  Cells stored at 4̊ C can be analyzed up to 24 hours after the procedure without significant changes in the count and differentials  Certain proteins may be temperature sensitive and the samples may need to be stored at -80̊ C
  8. 8. Correcting for Bronchoalveolar Lavage Dilution  Instilled fluid is mixed with the endogenous fluid in the alveoli  Alveolar space is also in contact with a vascular space- So water and solutes can transfer into the alveolar space This process leads to the uncertainty of any measurement of the concentration of any material in the alveolar space
  9. 9. Solution One method has been to report per mL of aspirated fluid. Using this correction method has allowed clinicians to quantitate the number of bacteria in the alveolar space and to therefore diagnose bacterial pneumonia
  10. 10. Unsatisfactory BAL specimen that shows squamous epithelial cells (large cells) and degenerating columnar epithelial cells (arrow)
  11. 11. Steps in Handling Cellular Population of Bronchoalveolar Lavage Fluid
  12. 12. Cellular Staining Papanicolaou Stain: -Detect Cancer & Infection -Not good at differentiating between inflammatory cells Toluidine blue staining: -Mast cells are better seen
  13. 13. Wright-Giemsa stain: -Good at differentiating between inflammatory cells Diff-Quik (modification of the Wright-Giemsa stain): -Is a rapid method allowing staining of the slide within a few minutes Limitations: -The cells must be adequately adhered to the slide prior to fixation -Some cells are underestimated by these techniques
  14. 14. Oil red O stain: -In fat embolism Fat and Lipid stain (e.g. Sudan III): -Lipoid pneumonia (aspiration) Lipid-laden alveolar macrophage index > 100 (Sensitivity of 100%, Specificity 57%) Periodic acid-Schiff (PAS): -Pulmonary alveolar proteinosis
  15. 15. Other stains KOH preparation: Fungal Auramine-rhodamine or Ziehl-Neelson: Mycobacterial
  16. 16. Modified acid fast stain (Kinyoun): Nocardia Silver methenamine: Pneumocystis jirovecii pneumonia, fungal Direct fluorescent antibody testing (DFA) for Legionella
  17. 17. Number of Cells Counted De Brauwer et al determined that between 300 and 500 cells counted provided a good representation of the number of nucleated cells for a BAL sample
  18. 18. Different cell types in respiratory tract  Upper respiratory tract Ciliated pseudostratified columnar cells Squamous cells  Trachea and bronchi Peudostratified Ciliated columnar cells Goblet cells
  19. 19.  Terminal bronchioles Low columnar or cuboidal-may be ciliated Club cells (Clara cells)-nonciliated, secretory cuboidal cells  Alveoli Type I pneumocytes-simple squamous alveolar cells Type-II pneumocytes-great alveolar cells Dust Cell-in the alveoli Alveolar macrophages- in the connective tissue of alveolar walls or interalveolar septa
  20. 20. General indications for BAL: -Non-resolving pneumonia - Diffuse lung infiltrates (interstitial and/or alveolar) - Infiltrates in an immunocompromised host - Suspected alveolar hemorrhage - Quantitative cultures for VAP - Exclusion of diagnosable conditions by BAL - Research
  21. 21. Gross examination- 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
  22. 22. Amorphous, predominantly acellular debris (pulmonary alveolar proteinosis)
  23. 23. Papanicolaou stain- foamy proteinaceous alveolar cast
  24. 24. Alveolar macrophages Normal >80% Decreased in Sarcoidosis (to 55% or less) Cell count and differential count
  25. 25. Predominance of alveolar macrophages in BAL from a normal subject
  26. 26. This photomicrograph shows an asbestos body under higher magnification, surrounded by alveolar macrophages
  27. 27. Neutrophils (Normal <3%): Nonspecific, but suggests active alveolitis Increased in: ARDS Connective tissue disorders Idiopathic pulmonary fibrosis Infection Pneumoconiosis Wegener's granulomatosis
  28. 28. BAL neutrophil predomnance with intracellular bacteria
  29. 29. Eosinophils (Normal <1-2%) Low to Moderate Eosinophilia (5-20%): Drug induced lung disease Minocycline Nitrofurantoin Penicillin Infections Parasitic Mycobacterial Fungal
  30. 30.  Bronchial Asthma  Malignancies (infrequently)  Other interstitial pneumonias occasionally (BOOP or COP, IPF/UIP, ILD associated with Connective tissue disorders, Sarcoidosis)
  31. 31. BAL eosinophilia
  32. 32. Moderate to Marked Eosinophilia (>20%):  Allergic bronchopulmonary aspergillosis  Acute eosinophilic pneumonia  Churg-Strauss syndrome  Chronic eosinophilic pneumonia  Idiopathic hypereosinophilic syndrome
  33. 33. Lymphocytes (Normal <15%) Normal CD4/CD8 (0.9-2.5:1): Tuberculosis Malignancies Low CD4/CD8: Hypersensitivity Pneumonitis Silicosis Drug-induced lung disease HIV infection BOOP (COP)
  34. 34. Elevated CD4/CD8: Active sarcoidosis (>4:1 up to 10:1) Asbestosis Berylliosis Crohn's disease Connective tissue disorders Sometimes in normal persons (inc. with age)
  35. 35. BAL Lymphocytosis
  36. 36. 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
  37. 37. Foamy macrophages: Non specific finding May be seen in amiodarone use Malignancies (sensitivity ranges from 35% to 70%) ◦ Lymphangitic carcinomatosis ◦ Lymphoma ◦ Bronchoalveolar carcinoma and other primary lung malignancies ◦ Extrapulmonary malignancies
  38. 38. Hemosiderin Laden Macrophages: 20% is highly specific and sensitive for alveolar hemorrhage  Langerhans cells >5% suggestive of Pulmonary Langerhans cell histiocytosis  Cytomegalic cells Viral pneumonias (cytomegalovirus, herpes) Sulfur granules: Actinomycetes
  39. 39. Microbiology Cultures Polymerase chain reaction (PCR)  TB and others Quantitative or semi-quantitative cultures  VAP
  40. 40. GMS BAL fluid showing round to cup shaped cysts of Pneumocystis
  41. 41. Pap-stained BAL fluid demonstrating large, retractile yeast forms of Blastomyces dermatiditis (400X)
  42. 42. Pap-stained BAL fluid showing variably-sized, round yeast forms of Cryptococcus neoformans (1000X)
  43. 43. Wright-stained BAL fluid demonstrating intracellular yeast forms of Histoplasma capsulatum
  44. 44. Wright-stained BAL fluid demonstrating oblong, budding yeast forms with pseudohyphae (1000X)
  45. 45. 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%)
  46. 46.  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 Mechanical Ventilation
  47. 47. Pulmonary alveolar microlithiasis Calcospherites can be demonstrated in BAL fluid (one of the tiny round bodies formed during calcification by chemical union of calcium particles and albuminous matter of cells)
  48. 48. Thank You