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Bronchoalveolar Lavage

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What is Bronchoalveolar Lavage?

• Bronchoalveolar lavage (BAL) is a simple minimally invasive process of collecting fluid and cells from the lungs for diagnosis purpose.

• With the help of medical device known as bronchoscopy we reach the lung and further to its subsegmental part where we inject normal sterile saline and then drawn it back into the syringe.

• The collected fluid is sent to the laboratory and tested for diagnosis of cause of infection, cancer, bleed and other lung related diseases.

Why and when is it done?

• For identifying an infection.

• Chronic cough

• Unexplained radiographic findings (X-ray or CT scan)

• Diffuse alveolar hemorrhage

• Pulmonary alveolar protienosis

• Eosinophilic pneumonia

• Hypersensitivity Pneumonitis

• Diagnosing tumor/cancer

• Chronic Berylliosis

• Interstitial Lung diseases

• Asbestos

• In immunocompromised patients ; for opportunistic pulmonary infections.

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Technique

• After sedating the individual and using numbing medication for the throat the procedure starts.

• Bronchoscope (flexible) is introduced inside the mouth and progressed into the windpipe and further.

• It has a fibre-optic light at its end for better visualization of the airway.

• A small suction port is present which aspirated the fluid and de-fogs the camera hence helps in better visualization of structure.

• Flexible tubes can be bend and help in better navigation around the small structures / lesions.

• Generally, the health professional used 20-60 ml of sterile normal saline of room temperature. (volume used ranges from 0.5 to 3 ml/kg in different studies)

• Injects the sterile saline with help of handheld syringe and then withdraws the saline back into the syringe.

• At least 5% of the injected saline should be able to be withdrawn back into the syringe (30% of the total saline injected should be the return sample collected), if not the procedure should be cancelled/ aborted as it indicates that the injected fluid is being retained in the lung.

• The process is repeated for 3-5 times and total of approximately 300 ml is used.

• Once the procedure is complete the tube is removed and lavage fluid obtained is send for testing. (note id made of the volume of fluid)

• It is stored and transported in cold (ice) within 1 hours of obtaining the lavage fluid, however studies show that BAL fluid can stay viable at room temperature for 4 hours.

• The fluid is studied for white and red blood cells.

• Ideal lavage fluid should have at least 2 million total cells not less than 10 alveolar macrophages per high power field.

• After BAL is performed then biopsies and brushings should be collected to avoid unnecessary red blood cells in the lavage fluid.

• Post procedure, individual would be be allowed to eat or drink for few hours until the sedation doesn’t wear off.

• Once sedation wear offs you can have ice chips or small sips of water to begin with and gradually have semi-solid food.

Chest x-ray is taken to see for signs of injury, if any they are treated before discharge.

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Preparation before the examination

• Individual is expected to fast for at least 6 to 12 hours before the procedure.

• Avoid taking blood thinning medications.

• Smoking history is important, since it increases the number of cells obtained by the lavage by 4-6 times (mainly macrophages).

• Aspirin has to be avoided before the procedure, consult your doctor if you are taking aspirin.

• Since individual will be given anesthesia, consent is required.

• Change into comfortable clothes/ gowns provided by hospital.

• Individual’s blood pressure, heart rate and oxygen levels are monitored before starting the procedure.

• Sedation is given and numbing mediation is sprayed in the throat (reduces gagging reflex).

• No history of heart attack , angina, uncontrolled arrhythmias or hemodynamic instability within the last 4 weeks.

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Complications

• Infection.

• Breathing difficulties.

• Sore throat (due to passage of the tube)

• Fever (seen in 30 % of patients)

• Collapse of lung – in case there is injury to the lung during the procedure• Irritation to the vocal cords

• Injury to the airway

• Collection of air between the pleura and lung (Pneumothorax)

• Heart issues, especially in individual with history of heart diseases.

• Alternation of blood pressure and heart rate (due to use of anesthesia).

• Nausea and vomiting (due to use of anesthesia)

• Muscular pain

• Heart arrest

• Injury to the teeth

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Alert signs

After procedure if one develops these signs, contact the doctor immediately:

• Fever >100.4°F (38°C)

• Blood in cough

• Chest pain

• Extreme change in voice (change in volume or pitch)

• Redness or swelling of the IV site

• Breathing difficulty traindications

• Heart diseases, history of arrhythmias

• Low oxygen levels

• Severe repetitive coughing

• Gagging reflex

• Pulmonary hypertension (high blood pressure in blood vessels of the lungs).

• In case of narrowing of windpipe (trachea)

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Advantages

• Helps to detect abnormalities which are not seen better on other imaging like X-rays or CT scans.

• Can identify cause of infection caused by bacterial, fungal or viruses which are not identified in blood reports.

• Removal of fluid from lungs.

• For delivering medicines

• Can have diagnostic as well therapeutic values.

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