Bronchoalveolar lavage (BAL) is a procedure that washes and samples the lung alveoli. It involves inserting a bronchoscope and instilling saline into a selected lung segment. The saline is then suctioned back to obtain a specimen for analysis. BAL analysis provides information on cell counts, microbiology, and cytology to help diagnose conditions like infection, hemorrhage, cancer, and interstitial lung diseases. It has a low risk of complications but can potentially cause cough, fever, or changes in lung function.

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LavageLavage
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Lecturer: RihamLecturer: Riham
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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
100-200ml, 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.

3. 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

4. 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

5. 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

6.  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)

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

8.  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)

9. Normal CD4/CD8 (0.9-2.5:1):
• Tuberculosis
• Malignancies
Low CD4/CD8:
• Hypersensitivity Pneumonitis
• Silicosis
• Drug-induced lung disease
• HIV infection
• BOOP (COP)
Others:
Lymphoma, Viral Pneumonia, Alveolar Proteinosis

10.  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

11. Microbiology
 Cultures
 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 others
 Quantitative or semi-quantitative cultures  VAP

12. Cytology
 Foamy macrophages: Nonspecific: amiodarone use
 Malignancies
◦ 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 hemorrhage
 Langerhans cells: >5% Pulmonary LCH
 Cytomegalic 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)

13. 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.

15. Thank You