Broncho alveolar Lavage

and Trans bronchial Lung

Biopsy

Dr Mohamed Hafeez
Broncho alveolar Lavage
• Orginally described in 1970’s
• Referred as “liquid lung biopsy “

• Concept - cells and noncellular components on the epithelial surface

of the alveoli are representative of
Inflammatory
Immune systems of the entire lower respiratory tract
Prebronchoscopy Evaluation
• In an American College of Chest Physicians (ACCP) survey, obtain a
preprocedure
Chest radiograph
Coagulation studies
Complete blood count.
Cardiac evaluation in patients with known coronary disease
undergoing elective bronchoscopy can be considered.
Preparation and Anesthesia
• Obtain informed consent.
• If an outpatient procedure, the patient should be accompanied by a
person designated to drive the patient.
• Keep the patient NBM for 4 hours.
• BAL should be planned to be performed prior to any other
bronchoscopic procedure to avoid specimen contamination.
• Review radiographs to determine ideal site of alveolar lavage.

• In diffuse infiltrates, the right middle lobe (RML) or the lingula in the
supine patient is preferred.
Procedural Medications
• Antisialogogues -for drying secretions and reducing the vasovagal response
Atropine 0.4 mg IM -most commonly used
Not recommended on a routine basis

• Benzodiazepines -provide amnesia and anxiolysis

Midazolam (adult dose 1 to 2.5 mg IV)
parenterally
fast onset of action
short half-life
• Flumazenil- can be used to reverse the sedative effects of benzodiazepines.
• Opiates decrease the laryngeal reflexes and cough response, and
provide some anxiolysis.
• Fentanyl (adult dose 25-100 mcg IV).
parenterally
Short onset of action.
Naloxone reverses opiate sedation through direct competitive
inhibition.
It should only be used in cases of a significant narcotic overdose
• Topical anesthesia- application of lidocaine, benzocaine, tetracaine
• Lidocaine
• most commonly used topical anesthetic
• Fast onset of action and wide therapeutic window.
• It is applied in the glotticarea, as well as directly on the tracheobronchial
tree.
• Safety for lidocaine - doses <7 mg/kg.
• Be aware -risk of methemoglobinemia when using even in small amounts -
can be reversed by administration of methylene blue
• should be minimized as there may be bacteriostatic effects of lidocaine.
•  Premedicate with bronchodilators and/or warm the saline solution
for those at risk for bronchospasm.
• Position patient- supine position
• Area That Is Lavaged -usually 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,
-lavage in the upper lobes had a higher yield
 Monitoring
• Apply monitors and supplemental oxygen.
• Additional assistance is required, including at least one respiratory
therapist.
• Assistants monitor the
 patient vital signs
Administer and record medications
Handle specimens, and assist with the bronchoscope and other
equipment.
Equipment
• Flexible bronchoscope
• Sterile collection trap
• Suction tubing
• Sterile saline Additional equipment needed for

• Vacuum source Endotracheal intubation

Cardiopulmonary resuscitation
• Syringe vascular access
needle decompression of pneumothorax
• Lidocaine 1-2%
Technique
• Perform preparatory steps and obtain adequate sedation

• The most common patient position is supine, with the operator standing at
the patient’s head.

• During insertion of the bronchoscope, note abnormalities of the upper

airway, false and true vocal cords, and glottis area.

• After examination of the airways, diagnostic or therapeutic procedures may

be attempted
 Bronchoscopic Findings

Important to know before interpreting bronchial brush cytology

Bronchoscopy appearance Interpretation
Pale pink Normal
Granulation tissue Inflammatory mucosal reaction
Irregularity of mucosa Early malignancy
Raised lesion Malignancy
Cauliflower like with pale yellow or white color Squamous cell carcinoma
Mulberry Adenocarcinoma
Necrotic appearance of mucosa Small cell carcinoma
Narrowing of airway Extrinsic compression by mediastinal nodes
BAL
• Advance bronchoscope until wedged in a desired subsegmental
bronchus

• Infuse 20mL of saline with a syringe, observing the flow of saline at

the distal tip of the bronchoscope.

• To obtain an adequate specimen 40-60 mL (usually 40-70% recovery

of the total instillate) must be drawn back.
• When the volume of saline is small (e.g. 10–20mL) and is sprayed into
the vicinity of a visible lesion, this procedure -bronchial washing

• Maintaining wedge position, apply gentle suction (50-80mmHg),

collecting the lavage specimen in the collection trap.
• Repeat steps, up to 5 times as needed (total 100-120 mL)
Handling of Aspirated Fluid
• At the time of the lavage , cells should be stored in silicone-coated or similar
containers .

• BAL specimen should be processed as soon as possible with desired tests

ordered.

• Cell counts should probably be made on unfiltered, unwashed, and

unconcentrated samples
Centrifugation to concentrate proteins and cells can lead to loss of cells
Washing the cells can change the differential count considerably
Satisfactory Sample

• A total of 2×106 cells -minimum requirement

• > 10 macrophages

• Degenerative changes should cover < 20% of the specimen area on

the slide

• Number of Cells Counted between 300 and 500 nucleated cells

Lavage procedure is considered invalid
• 1. There is a presence of purulent secretions (the number of
squamous epithelial cells, bronchial cells, RBCs, or inflammatory cells
exceeds that of macrophages )in the airways.

• 2. Bronchoscope is not maintained in wedge position during lavage.

• 3. Volume of fluid recovered < 40% of the volume infused.

The Storage of Fluid

• Cells stored at 4̊ C can be analyzed up to 24 hours after the procedure

• Certain proteins may be temperature sensitive and the samples may

need to be stored at -80̊ C
• The volume of fluid used to sample more peripheral lung is commonly
in the order of 60mL (given as two 30-mL aliquots) and frequently
gives a return on suction of about 10–15mL.

• When 60mL or more is used the technique can fairly be described as

‘broncho alveolar’ rather than ‘bronchial’ washing.
General indications:
1. In patients with pulmonary infiltrates
• Non-resolving pneumonia

 Diffuse lung infiltrates (interstitial and/or alveolar)

Infiltrates in an immunocompromised host- to search for

opportunistic organisms such as P. carinii (e.g. AIDS, after transplant,
acute leukaemia, myeloma, etc.)
Exclusion of diagnosable conditions by BAL, usually Infections - Fungal
,Viral

Mycobacterial Bacterial -when no organisms in sputum

 occasionally a cavitating lesion suggestive of tuberculosis turns out
to be neoplastic, send BAL fluid for cytology as well
When this organism is suspected, an upper lobe is often chosen as
this may provide a greater yield.
2. Diagnosis and staging of interstitial lung diseases

• a. Specific interstitial lung diseases

• I. Idiopathic pulmonary fibrosis (IPF)
• II. Pulmonary fibrosis associated with collagen vascular disorders (PF-CV)
• III. Hypersensitive pneumonitis (HSP)
• IV. Extrinsic allergic alveolitis (EAA)
• V. Pneumoconiosis- Asbestos related interstitial disease , Silicosis
,Beryllosis
• VI. Sarcoidosis
• Rare interstitial lung disease- Histiocytosis-X
• 3.Alveolar filling process –
 Suspected alveolar hemorrhage
Alveolar proteinosis
Fat embolism and lipoid pneumonia
• 4.Detection of lung cancer
Lymphangitic carcinomatosis
 Bronchoalveolar carcinoma
 Other malignancies
• 5.Research
• the cellular constituents of lavage fluid/ the nature of epithelial lining fluid
• As a generalization and where BAL is used, >105cfu has been taken as a
threshold indicating probable pneumonia, <104cfu indicating probable
absence of pneumonia
Normal Constituents of BAL

• In a nonsmoker:
• Alveolar macrophages > 85%
• Lymphocytes 10-15%
• Neutrophils < 1%
• Eosinophils < 1%
• Ciliated columnar cells < 2 %
• T4 : T8 ratio 0 .9–2.5

• In smokers
• Cell yield is four times greater, slightly increased number of neutrophils.
BAL: Cell counts are useful in the diagnosis and prognosis of certain
disorders

1.Cell counts
• The presence of increased nucleated cells is of no diagnostic or
prognostic value

• 2. Diagnosis
• Infective agent
• Malignant cells
 Reasons for increase in various types
of inflammatory cells
 Neutrophils (Normal <3%): Increased in
Nonspecific, but suggests active alveolitis ARDS

Connective tissue disorders -Idiopathic pulmonary

fibrosis

Infection

 Pneumoconiosis

Collagen vascular disorder

 BAL neutrophil predomnance with intracellular

bacteria
Eosinophil's (Normal <1- Low to Moderate Moderate to Marked
2%) Eosinophilia (5-20%): Eosinophilia (>20%):

Drug induced lung Allergic

disease -Minocycline bronchopulmonary
,Nitrofurantoin, Penicillin aspergillosis

Infections -Parasitic Acute eosinophilic

Mycobacterial Fungal pneumonia

Bronchial Asthma Churg-Strauss syndrome

Malignancies Chronic eosinophilic

(infrequently) pneumonia

Other interstitial Idiopathic

pneumonias occasionally hypereosinophilic
(BOOP or COP, IPF/UIP, ILD syndrome
associated with Connective
tissue disorders,
Sarcoidosis)
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)

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)

Alveolar macrophages Normal >80% Decreased in Sarcoidosis (to 55% or less)

 Cell Counts in Evaluating Prognosis of the
Disease
Idiopathic pulmonary ↑ T lymphocytes—good
fibrosis (IPF) prognosis
Collagen vascular disease ↑ Neutrophils—presence
of interstitial involvement
HSP ↑ T8 protects against
pulmonary fibrosis
Sarcoidosis T4:T8 normal—stable
Berylliosis course of diseases
Asbestosis Presence of asbestos
body—indicates exposure
↑ Eosinophils in IPF—
poor prognosis
↑ Lymphocytes—
clinically stable collagen
vascular disease.
T4: T8—↑ -deterioration BAL lymphocytes > 35%
in clinical course Poor response to therapy
BAL lymphocytes < 35%
Good response to therapy
Asbestos body with increased lymphocytes,
neutrophils and eosinophils indicates subclinical
pulmonary involvement
 Analysis of fluids and miscellaneous
specimen
Bronchial epithelial cells Normal, more in bronchial wash specimens
Elevated erythrocyte count - early sign of alveolar hemorrhage (first several hours)
Hemosiderin Laden Macrophages alveolar haemorrhage > 48hrs
Phagocytised erythrocytes alveolar hemorrhage within 48 hrs
Langerhans cells >5% Pulmonary Langerhans cell histiocytosis ,cigarette
smokers

Cytomegalic cells Viral pneumonias (cytomegalovirus, herpes)

Sulfur granules Actinomycetes

Foamy macrophages Non specific finding May be seen in amiodarone use

Calcospherites (tiny round bodies formed during Pulmonary alveolar microlithiasis
calcification by chemical union of calcium particles and
albuminous matter of cells)
Clumps of amorphous lipoproteinaceous material alveolar proteinosis

Fat droplets/lipid laden macrophages Fat embolism

Dust particle inclusions Pneumoconiosis or asbestosis exposure

Malignancies (sensitivity ranges from 35% to 70%) Lymphangitic carcinomatosis

Lymphoma
Bronchoalveolar carcinoma and other primary lung
malignancies
Extrapulmonary malignancies
Microbiology
• Cultures
eg- MGIT (Mycobacteria Growth Indicator Tube)-determines whether or
not TB bacteria will grow in the presence of TB drugs

• Stains and Immunohistochemistry

• Polymerase chain reaction (PCR)

• Quantitative or semiquantitative cultures

Diagnostic of infection if organism identified

• Pneumocystis carinii
• Toxoplasma gondii
• Strongyloides stercoralis
• Legionella pneumophila
• Cryptococcus neoformans
• Histoplasma capsulatum
• Mycobacterium tuberculosis
• Mycoplasma pneumoniae
• Influenza A and B viruses
• Respiratory syncytial viru
Cellular Staining
Papanicolaou Stain
Toluidine blue staining
Wright-Giemsa stain
Oil red O stain
Lipid stain (e.g. Sudan III)
Periodic acid-Schiff (PAS)
KOH preparation
Detect Cancer & Infection -Not good at differentiating
between inflammatory cells
Mast cells
Good at differentiating between inflammatory cells
Is a rapid method allowing staining of the slide within
a few minutes
fat embolism
Lipoid pneumonia (aspiration)
Pulmonary alveolar proteinosis
Fungal
Ziehl-Neelson/Auramine-rhodamine Mycobacterial

Modified acid fast stain (Kinyoun) Nocardia

Silver methenamine Pneumocystis jirovecii pneumonia

fungal Direct fluorescent antibody testing (DFA) Legionella

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
Trans bronchial lung biopsy (TBLB)
Trans bronchial lung biopsy
• Trans bronchial (sometimes referred to as ‘bronchoscopic’) - biopsies
are made beyond the limits of direct vision
• Performed by passing biopsy forceps through the bronchoscope and
into the lung, with the goal of sampling the distal airways
parenchyma.
• Generally performed using fluoroscopic guidance- not absolutely
necessary
Area being sampled is too distal for direct visualization .
Wedge technique
• Where there is diffuse disease that is bilateral, the tip of a larger-
channel bronchoscope may be wedged into a laterally placed
segmental bronchus in either lower lobe.

• At this point, 5mL of 1:20000 epinephrine solution is injected into the

chosen segmental orifice in the belief that this diminishes the
likelihood of serious bleeding
• The largest possible toothed biopsy forceps are then passed through
the same segmental opening, while the end of the bronchoscope
remains wedged into that segment

• The shaft of the bronchoscope nearest the patient being held by the
assistant, with gentle inward pressure, so that the bronchoscopist is
free to advance the forceps
Precaution
• If the forceps reach the extreme periphery of the lung, pleuritic pain
may be felt and the forceps are withdrawn a few centimetres to
reduce the chance of pneumothorax.

• If the forceps are arrested early on in their journey, another basal

segment is tried instead, as too proximal a biopsy runs a small risk of
damaging a larger blood vessel
• When the forceps appear to be well situated towards the lung
periphery

• Ask the patient to ‘take a deep breath in and hold it’ and

• The assistant is given the instruction ‘open’.

• The forceps can often be seen to open on the fluoroscopy screen, and
they are then pushed gently forwards until resistance is felt

• Ask the patient ‘let all your air out’

• assistant is given the instruction ‘close’ when expiration is seen to be

complete.

• Hold the forceps close for a moment before retracting the forceps
• The forceps are then firmly withdrawn.

• An elastic tug followed by a feeling of ‘give’ is sensed and lung tissue

may be seen to be pulled and to recoil back into place on the screen.

• This is usually a sign that a satisfactory biopsy has been obtained.

• The biopsy material is then placed in fixative for histopathology or

normal saline for microbiology.
 Cupped forceps

Alligator forceps
• Trans bronchial lung biopsy depends for its success on the forceps
having invaginated and torn away lung tissue as well as bronchial
mucosa.

• While the assistant is attending to the specimens, the bronchoscopist

holds the end of the bronchoscope firmly wedged up against the
segment just sampled so that any local bleeding is contained
• The procedure is then repeated in the same segment so that the
bronchoscope continues to tamponade effectively.

• In diffuse disease, three adequate looking samples are probably

sufficient for histology , although some work has shown an increase in
positive histological yield with up to six biopsies .

• Avoid the lingula and right middle lobe because of proximity to

fissures and risk of pneumothorax
• By the time all the biopsies have been taken
 vision has usually been obscured by local bleeding and it is wise to
keep the instrument wedged in the segmental bronchus for at least
5min in order to enable clot to form and to prevent bleeding once the
instrument is removed.

The same technique may be used to biopsy mass lesions that are
situated peripherally (i.e. beyond bronchoscopic vision), provided that
they are of sufficient size to be seen fluoroscopically and that the
forceps can be directed towards them.
Specimen Handling
• specimens are collected –
 opening the cusps and gently shaking the forceps in sterile saline
A toothpick may be used to retrieve the specimen from the biopsy
forceps

• Specimens can be transferred to a container with 10 % formalin for

routine pathological examination.
• When infectious disease is likely, one or more tissue specimen may be
submitted to the microbiology laboratory in sterile Ringer’s lactate.

• A pale fluffy looking specimen that floats is likely to be a good one,

although one that sinks need not mean failure.

• TBBx specimens with alveolar tissue were more likely to float on 10 %

formalin than specimens without alveolar tissue
• It is possible to carry out trans bronchial lung biopsies on patients
who are being ventilated mechanically .
• The risks should be expected to be greater in an intensive care
situation because of the increased likelihood of associated problems
in critically ill patients.
• These include serious hypoxaemia, bleeding and pneumothorax
(particularly with positive end-expiratory pressure), and fluoroscopy
should be used in this situation
Indication
Malignancy
Lung cancer , Pulmonary nodule or mass

Metastasis
Infections
Tuberculosis • Non-tubercular mycobacterial infections • Fungal infection • Pneumocystis pneumonia • Viral
infections such as CMV pneumonitis
Acute lung transplant rejection
Undiagnosed infiltrates in mechanically ventilated patients
Diffuse lung diseases
Sarcoidosis • Lymphangitic carcinomatosis • Pulmonary alveolar proteinosis • Pulmonary Langerhan’s
histiocytosis • Alveolar microlithiasis • Amyloidosis • Lymphangioleiomyomatosis • Bronchiolitis obliterans
with organizing pneumonia ,Drug-induced pneumonitis
Lung transplant Surveillance
Contraindications
• Increased ICP
Coughing during the procedure can further increase ICP leading to
brain herniation

• Inadequate equipment & Insufficient training

• Refractory hypoxemia

• Uncorrected coagulopathy , patient on anticoagulation

• Pulmonary hypertension (may increase bleeding risk)

• Undue risk for respiratory failure or death in case of TBLB-related pneumothorax

or bleeding

• Active myocardial ischemia

• Thrombocytopenia

• Uremia (increases risks of bleeding)

Specific recommendation

Proceed with TBBx only when: PT-INR < 1.5, • aPTT < 50 s, platelet counts > 50 K

aspirin or NSAID No need to stop

clopidorel, ticlodipine, and prasugrel Stop for 5–7 day
Coumadin Hold for 3 days; check PT-INR before the procedure

unfractionated heparin Hold for 6 h and check aPTT before the procedure
low-molecular-weight heparin Hold for at least 12 h
Oral anti coagulants Hold dabigatran and rivaroxaban for 2 days (hold for •
a longer period in presence of renal insuf fi ciency)
Fluoroscopy guided TBLB
• Frequency of pneumothorax possibly decreased.

• Avoids causing pleuritic chest pain with forceps.

• Avoids need for post bronchoscopy radiograph because fluoroscopic

examination at end of procedure determines presence or absence of
TBLB-related pneumothorax.
•
Improves physician ease, comfort, and security
Complications
• Pneumothorax - Risk 1-4 %

• Hemorrhage 1.2 – 40%.

Bleeding > 50 ml approximately 1-2%
Increased in uremia and immunocompromised patients
 The minimal platelet count necessary prior to performing-requirement
of a count greater than 50¥109/L is usual

• Death -Risk estimated at 0.04 -0.12 %

• Anesthesia-Related Complication
• Topical anaesthetics may cause epileptic seizures and cardiac
dysrhythmias
• sedative drugs that may result in hypoventilation.
• A maximum dose of 300–400mg of lidocaine has been recommended
for topical anaesthesia
• Laryngospasm may occur, possibly as a result of inadequate
anaesthetization of the larynx
• Respiratory and cardiovascular complications
• Cardiovascular complications range from minor vasovagal episodes to
serious cardiac dysrhythmias, myocardial infarction and pulmonary
oedema
Precautions
• Systemic coagulopathy, which should be corrected with appropriate
replacement, such as fresh frozen plasma, vitamin K, etc., before
biopsy is undertaken.

• Correction of thrombocytopenia -Transfuse platelets if counts are <50

K and check counts immediately prior to TBBx

• Avoidance of biopsy or brushing in patients with uraemia which also

impaires platelet function.
 For BUN >30 mg/dl and creatinine >3.0 mg/dl
• administer DDAVP(Desmopressin ): 0.3 m g/kg IV in 50 ml of saline
and administer over 30 min
• start infusion 60 min prior to procedure, or 3 m g/kg intranasal spray
30 min prior to TBBx

• Local application of 5mL of 1:20000 epinephrine solution before

biopsy.
• Use of the ‘wedge technique’, where the bronchoscope tip tamponades
a bleeding segment

• Availability of a balloon catheter of suitable size for passage down the

suction channel in order to tamponade a bleeding bronchus .

• If such a catheter is not available in the presence of massive

haemorrhage, asphyxiation may be prevented by isolating the bleeding
lung with a single-lumen endotracheal tube passed into the other main
bronchus.
• Such ‘blind’ intubation until resistance is felt usually places the tube in
the right main bronchus, allowing ventilation of the middle and lower
lobes.
• It may also be possible to selectively intubate the left main bronchus
when the right side is bleeding, by passing the tube with the patient’s
head turned to the right and with appropriate positioning of the bevel
of the tube
• It is also usual to place patients on their side, with the bleeding lung
most dependent in order to protect the other lung.
Post procedure
• The patient requires monitoring until recovered from sedation.

• At the end of the procedure the channel of the bronchoscope may be

rinsed out into a container with 10–20mL normal saline so that
cellular debris lost from brushes or biopsy forceps may be similarly
sampled.
 Postprocedure
Chest radiograph – generally obtained

If needle aspirations or biopsies have been performed.

Trans bronchial biopsy should not be carried out bilaterally at the

same session because of the small but real risk of bilateral
pneumothoraces.
Endobronchial biopsy
• Performed by passing biopsy forceps through the bronchoscope and
sampling airways lesions in the larger airways under direct
visualization.

• Transbronchial needle aspirations (TBNA)

• Used to take cytologic samples from enlarged mediastinal lymph
nodes and masses.
Bronchial brushings
• Cell samples are obtained with small brushes under visual control by
fiberoptic bronchoscope or by employing imaging guidance
technique.
• Brushings should be done prior to biopsy procedure to prevent
contamination of the specimen by blood.
• Brush is smeared directly on to a microscope slide using a circular
motion,each slide being immediately fixed in 95% ethanol.
• Bronchial aspirates are obtained by introducing the bronchosope in
the lower respiratory tract and aspirating the secretions by suction
apparatus.

• Bronchial washings from the visualized areas are collected by instilling

3–5 ml of a balanced salt solution through the bronchoscope and
reaspirating.
• Thank you
Inspections Evaluation,diagnosis Management Other
Upper aerodigestive tract Chronic cough,Wheezing Tracheoesophageal fistula Assisting in intubation and
extubation
Larynx lesions of unknown etiology  Stage lung carcinoma and Assisting percutaneous
on X-rays as Persistent evaluate response to tracheostomy
pulmonary infiltrates, therapy
atelectasis or unexplained
hemoptysis.
Vocal cords(unexplained  Origin of unexplained Tracheobronchial stenosis Brachy therapy
paralysis of vocal cord) positive sputum cytology
Major conductive airways Obtain microbiological Foreign body Intra lesional injection of
material for suspected drugs
pulmonary infections
Investigate, superior vena Diffuse and focal lung disease Persistent atelectasis Brachytherapy
cava syndrome, chylothorax
Thermal/chemical inhalation Lyphadenopathyy Stent placement
injury
Anastomotic sites after lung Pulmonary nodule Surveillance for rejection
transplantation after lung transplant
Position/patency of ETT Investigate unexplained
pleural effusion