Although the technique of washing t...

Although the technique of washing the lung with physiologic saline solution to make a clean sweep of accumulated material has been used therapeutically for many years, it was with the advent of the use of flexible fiberoptic bronchoscopy in the 1970 that bronchoalveolar lavage (BAL) became an important clinical and investigational tool. The universal on which the use of BAL is based is that small cavitys and noncellular components present in succession the epithelial surface of the alveoli are representative of the inflammatory and immune classification of the entire lower respiratory tract. In addition, BAL allows sampling of various constitutings of the inflammatory and immune hypothesis at their site of action.[1] Although the value of BAL in the management of the immunocompromised patient (including AIDS) has become increasingly apparent, this review will discuss to what degree BAL may be useful in the clinical management of nonimmunocompromised conditions, in particular, interstitial lung disease, lung cancer, and bacterial/nosocomial pneumonia.

TECHNIQUE

The techniques utilized in performing BAL and processing the fluid are not standardized from common institution to another, which may account in part for the variability in reported consequence s Initial volume of fluid infused may be single in kind important variable among laboratories. We not long ago examined the results of 58 BALs performed in succession 55 patients with nonfocal interstitial lung disease in which one as well as the other a 100-ml (20 cc x 5) and a 250-ml (50 cc x 5) lavage were performed in the same lobe of the lung along with a 100-ml BAL forward the contralateral side. Although the percent answer was slightly higher with the large-volume BAL, there were no significant differences in confined apartment differentials or cell concentrations between 100-ml and 250-ml BAL.[2] Consequently for clinical plans a small-volume BAL of 100 to 150 ml may be preferable, since large-volume lavage may be associated with increased morbidity (see below). When localized disease is apparent radiographically, BAL should be carried not at home in multiple sites; in this setting, the make up fored cells and proteins may differ from site to site. It has also been noted that the percentage of fluid retrieveed and total cell counts are lower if the process is performed using general anesthesia v local anesthesia.[3]

The concentration of starch-sugar in BAL fluid is approximately 40 [mu]g/ml and of protein is about 006 mg/ml of which 30 percent is albumin.[4] repaired BAL fluid contains adequate nutrients. Rankin et al[5] place that the viability of lonely dwellings obtained by BAL was maintained when the lavage fluid was maintained at 25 [degrees] C for up to 4 h and that it is not necessary to add either agriculture medium or antibiotics to lavage specimens for transport to a centralized laboratory.

SAFETY AND COMPLICATIONS

A delayed febrile answer may occur in 10 to 50 percent of patients who sustain BAL; usually this does not portray pulmonary infection but a transient pyrogen drift that can be treated with antipyretics.[4] Strumpf et al[6] noted febrile disease in 2.5 percent of patients who underwent 100 to 150 ml of BAL. cabbage et al[7] noted fever in approximately 20 percent of their patients who underwent large-volume (300 to 500 ml) BAL and Pingleton et al[8] noted agitations chills, and myalgias in nearly 50 percent of normal proffers who underwent extensive lavage of four lobes. Thus, the incidence of febrile affection seems to be related to as well-as; not only-but also; not only-but; not alone-but the number of lobes lavaged and the total bulk of fluid instilled into each lavage site.

Gurney et al[9] prospectively evaluated the radiographic manifestations of lavage. In their reflection 30 minutes after lavage, 90 percent (47/52) of lobes lavaged revealed homogeneous areas of of recent origin or increased consolidation, most oftentimes in the peripheral portion of the lobe. Usually the margins were indistinct, and prominent air bronchograms were not near Resolution of these opacities was gradual, with opacities remaining in 91 percent (of the 47) at 90 min, 73 percent at 240 min, and all had cleared according to 24 h. The mien of these opacities correlated with the amount of retained saline solution, were limited to the area lavaged, and were not associated with clinical complications. The authors conclud that following BAL these benign, fleeting opacities related to the BAL should be considered in the differential diagnosis of modern chest x-ray findings.[9]

INTERSTITIAL LUNG DISEASE OF UNKNOWN ETIOLOGY

The interstitial lung diseases are a arrange of greater than 100 different disorders which are frequently disabling, sometimes fatal, and are characterized morphologically by way of an increase in the number of inflammatory and immune effector confined apartments within the lung parenchyma, ie, a chronic alveolitis. The alveolitis appears to introduce and modulate the derangement of alveolar constitutions including thickening and fibrosis of the adjacent interstitium. The latter changes may eventually lead to sufficient damage to interfere with convenient gas exchange.[1] If this observation is valid, knowledge of the carriage and intensity of the alveolitis by way of BAL may be important in planning and/or evaluating therapeutic strategies in these illnesses. The data that generally exist to address these questions in specific diseases are discussed below.