Diagnostic bronchoalveolar lavage
Last reviewed: 23.04.2024
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The idea of flushing the bronchus for emptying of the contents belongs to Klin and Winternitz (1915), who conducted BAL in experimental pneumonia. In the clinic, bronchoalveolar lavage was first performed by Yale in 1922 as a therapeutic manipulation, namely for the treatment of phosgene poisoning in order to remove a profuse secretion. Vincente Garcia in 1929 used from 500 ml to 2 liters of fluid with bronchiectasis, gangrene of the lung, foreign bodies of the respiratory tract. Galmay in 1958 applied massive lavage in postoperative atelectasis, aspiration of gastric contents and presence of blood in the respiratory tract. Broom in 1960 made a flushing of the bronchi through the intubation tube. Then, double-lumen tubes began to be used.
In 1961, QN Myrvik et al. In the experiment, airway flushing was used to obtain alveolar macrophages, which can be considered the birth of an important diagnostic method - bronchoalveolar lavage. For the first time the study of lavage fluid obtained through a rigid bronchoscope was undertaken by RI Keimowitz (1964) for the determination of immunoglobulins. TN Finley et al. (1967) used a balloon catheter Metra to obtain a secret and study it in patients with chronic obstructive pulmonary disease. In 1974, HJ Reynolds and HH Newball first received a fluid for study during a fibrobronchoscopy performed under local anesthesia.
Bronchoalveolar lavage is an additional study to establish the nature of pulmonary disease. Bytes ronhoalveolyarny lavage is a procedure in which the bronchoalveolar area of the respiratory tract was washed with isotonic sodium chloride solution. This is a method of obtaining cells and fluid from deep-seated areas of lung tissue. Bronchoalveolar lavage is necessary for both basic research and clinical purposes.
In recent years, the frequency of pathological processes, the main symptom of which is the increasing shortness of breath, has increased significantly.
Diagnostic bronchoalveolar lavage is indicated in patients who, when radiographing chest organs, have unclear changes in the lungs, as well as diffuse changes. Diffuse interstitial lung diseases represent the greatest difficulty for clinicians, since their etiology is often unknown.
Indications for bronchoalveolar lavage include interstitial infiltration (sarcoidosis, allergic alveolitis, idiopathic fibrosis, histiocytosis X, pneumoconiosis, collagenosis, carcinomatous lymphangitis) and alveolar infiltrations (pneumonia, alveolar bleeding, alveolar proteinosis, eosinophilic pulmonitis, obliterating bronchiolitis).
Unclear changes can be infectious, non-infectious, malignant etiology. Even in cases where lavage is not diagnostic, the result can be assumed to be a diagnosis, and then the attention of the doctor will be focused on the necessary further studies. For example, even in normal lavage fluid there is a high probability of detecting various disorders. Later, bronchoalveolar lavage is potentially used in determining the degree of disease activity, to determine the prognosis and the necessary therapy.
Every year, bronchoalveolar lavage is increasingly used in the treatment of various lung diseases, such as cystic fibrosis, alveolar microlithiasis, alveolar proteinosis, and lipoid pneumonia.
After inspection of all bronchi, the bronchoscope is injected into the segmental or subsegmental bronchus. If the process is localized, the corresponding segments are washed; for diffuse diseases, fluid is injected into the bronchi of the middle lobe or ligule segments. The total number of cells obtained by washing these sections is higher than with lavage of the lower lobe.
The procedure is as follows. Bronchoscope is led to the mouth of the subsegmental bronchus. As a lavage liquid, a sterile isotonic sodium chloride solution is used, heated to a temperature of 36-37 ° C. The liquid is inserted through a short catheter inserted through the biopsy channel of the bronchoscope and immediately aspirated into a silicone tank. It is not recommended to use an ordinary glass cup, since alveolar macrophages adhere to its walls.
Usually injected 20-60 ml of liquid repeatedly, only 100 - 300 ml. The volume of the resulting flush is 70-80% of the volume of the injected saline solution. The resulting bronchoalveolar lavage is immediately sent to a laboratory where it is centrifuged at 1500 rpm for 10 minutes. From the sediment prepare swabs, which after drying are fixed with methyl alcohol or a mixture of Nikiforov, and then painted according to Romanovsky. In a light microscope with the use of oil technology, no less than 500-600 cells are counted, differentiating alveolar macrophages, lymphocytes, neutrophils, eosinophils and other cells.
Bronchoalveolar lavage taken from the source of destruction is not suitable for studying the pathogenetic mechanisms of the disease, as it contains cellular detritus, a large number of neutrophils, intracellular enzymes and other elements of tissue decay. Therefore, to study the cellular composition of ALS, it is necessary to take a wash from the lung segments adjacent to the destruction.
There is no analysis of ALS containing more than 5% of the bronchial epithelium and / or 0.05 x 10 cells per ml, since, according to the studies of W. Eschenbacher et al. (1992), these indicators are characteristic for flushes derived from bronchi, and not from bronchoalveolar space.
Bronchoalveolar lavage is a simple, non-invasive and well tolerated study. There was only one report in the press about a patient who died on a background of acute pulmonary edema and septic shock due to bronchoalveolar lavage. The authors suggest that the lightening deterioration of this patient's condition is associated with a massive release of inflammatory mediators, which resulted in pulmonary edema and multiple organ failure.
Most of the reports of complications of bronchoalveolar lavage are associated with complications in bronchoscopy or depend on the volume and temperature of the fluid administered. Complications associated with BAL include coughing during the procedure, transient fever a few hours after the test. The total percentage of complications of bronchoalveolar lavage does not exceed 3%, it increases to 7% when performing a transbronchial biopsy and reaches 13% when an open lung biopsy is performed.
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