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Basic principles and technique of bronchoalveolar lavage

Talmadge E King, Jr, MD
Section Editor
Praveen N Mathur, MB;BS
Deputy Editor
Helen Hollingsworth, MD


Bronchoalveolar lavage (BAL), performed during flexible bronchoscopy, has gained widespread acceptance as a minimally invasive method that provides important information about immunologic, inflammatory, and infectious processes taking place at the alveolar level [1]. Studies comparing BAL cellular constituents to cells obtained from open lung biopsy have shown that the cell types and their state of activation are similar with either collection method.

This review will consider the basic principles and technique of BAL. The utility of this procedure in individual diseases is discussed in the appropriate topic reviews. The use of preprocedure medication, topical anesthesia of the upper airway, and techniques for the passage of the bronchoscope into the lung are discussed elsewhere. (See "Flexible bronchoscopy in adults: Indications and contraindications" and "Flexible bronchoscopy in adults: Overview".)


Bronchoalveolar lavage (BAL) has been widely used in patients with a variety of lung diseases [2]. Advantages with this technique include its noninvasive nature and ability to readily sample alveolar contents.

As a result, it has an important role in management of diffuse lung diseases for the following reasons [3,4]:

It is an excellent method to obtain specimens to rule out opportunistic infections in immunocompromised hosts [5]

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Literature review current through: Nov 2017. | This topic last updated: Jul 21, 2016.
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  1. Meyer KC, Raghu G, Baughman RP, et al. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med 2012; 185:1004.
  2. Costabel U, Guzman J. Bronchoalveolar lavage. In: Interstitial lung disease, 5th, Schwarz MI, King TE, Jr (Eds), People's Medical Publishing House-USA, Shelton, CT 2011. p.149.
  3. Stoller JK, Rankin JA, Reynolds HY. The impact of bronchoalveolar lavage cell analysis on clinicians' diagnostic reasoning about interstitial lung disease. Chest 1987; 92:839.
  4. King, TE Jr. Interstitial lung disease. In: Feinsilver, SH, Fein, AM (Eds), Textbook of Bronchoscopy, Williams & Wilkins, Baltimore, 1995, p. 185.
  5. Brownback KR, Simpson SQ. Association of bronchoalveolar lavage yield with chest computed tomography findings and symptoms in immunocompromised patients. Ann Thorac Med 2013; 8:153.
  6. Elston WJ, Whittaker AJ, Khan LN, et al. Safety of research bronchoscopy, biopsy and bronchoalveolar lavage in asthma. Eur Respir J 2004; 24:375.
  7. Baughman RP. Technical aspects of bronchoalveolar lavage: recommendations for a standard procedure. Semin Respir Crit Care Med 2007; 28:475.
  8. King TE Jr. Handling and analysis of bronchoalveolar lavage specimens. In: Bronchoalveolar Lavage, Baughman RP (Ed), Year Book Medical Publishers, Philadelphia 1991. p.3.
  9. Helmers RA, Dayton CS, Floerchinger C, Hunninghake GW. Bronchoalveolar lavage in interstitial lung disease: effect of volume of fluid infused. J Appl Physiol (1985) 1989; 67:1443.
  10. Radhakrishna N, Farmer M, Steinfort DP, King P. A Comparison of Techniques for Optimal Performance of Bronchoalveolar Lavage. J Bronchology Interv Pulmonol 2015; 22:300.
  11. Seijo LM, Flandes J, Somiedo MV, et al. A Prospective Randomized Study Comparing Manual and Wall Suction in the Performance of Bronchoalveolar Lavage. Respiration 2016; 91:480.
  12. Löfdahl JM, Cederlund K, Nathell L, et al. Bronchoalveolar lavage in COPD: fluid recovery correlates with the degree of emphysema. Eur Respir J 2005; 25:275.
  13. Kneidinger N, Warszawska J, Schenk P, et al. Storage of bronchoalveolar lavage fluid and accuracy of microbiologic diagnostics in the ICU: a prospective observational study. Crit Care 2013; 17:R135.
  14. Goh NS, Veeraraghavan S, Desai SR, et al. Bronchoalveolar lavage cellular profiles in patients with systemic sclerosis-associated interstitial lung disease are not predictive of disease progression. Arthritis Rheum 2007; 56:2005.
  15. Chou CW, Lin FC, Tung SM, et al. Diagnosis of pulmonary alveolar proteinosis: usefulness of papanicolaou-stained smears of bronchoalveolar lavage fluid. Arch Intern Med 2001; 161:562.
  16. Rottoli P, Magi B, Perari MG, et al. Cytokine profile and proteome analysis in bronchoalveolar lavage of patients with sarcoidosis, pulmonary fibrosis associated with systemic sclerosis and idiopathic pulmonary fibrosis. Proteomics 2005; 5:1423.
  17. Fietta A, Bardoni A, Salvini R, et al. Analysis of bronchoalveolar lavage fluid proteome from systemic sclerosis patients with or without functional, clinical and radiological signs of lung fibrosis. Arthritis Res Ther 2006; 8:R160.
  18. Harbeck RJ. Immunophenotyping of bronchoalveolar lavage lymphocytes. Clin Diagn Lab Immunol 1998; 5:271.
  19. Welker L, Jörres RA, Costabel U, Magnussen H. Predictive value of BAL cell differentials in the diagnosis of interstitial lung diseases. Eur Respir J 2004; 24:1000.
  20. Smith PA, Kohli LM, Wood KL, et al. Cytometric analysis of BAL T cells labeled with a standardized antibody cocktail correlates with immunohistochemical staining. Cytometry B Clin Cytom 2006; 70:170.
  21. Smetana K Jr, Mericka O, Saeland S, et al. Diagnostic relevance of Langerin detection in cells from bronchoalveolar lavage of patients with pulmonary Langerhans cell histiocytosis, sarcoidosis and idiopathic pulmonary fibrosis. Virchows Arch 2004; 444:171.
  22. Takizawa Y, Taniuchi N, Ghazizadeh M, et al. Bronchoalveolar lavage fluid analysis provides diagnostic information on pulmonary Langerhans cell histiocytosis. J Nippon Med Sch 2009; 76:84.
  23. Baqir M, Vassallo R, Maldonado F, et al. Utility of bronchoscopy in pulmonary Langerhans cell histiocytosis. J Bronchology Interv Pulmonol 2013; 20:309.
  24. Bronchoalveolar lavage constituents in healthy individuals, idiopathic pulmonary fibrosis, and selected comparison groups. The BAL Cooperative Group Steering Committee. Am Rev Respir Dis 1990; 141:S169.
  25. Heron M, Grutters JC, ten Dam-Molenkamp KM, et al. Bronchoalveolar lavage cell pattern from healthy human lung. Clin Exp Immunol 2012; 167:523.
  26. Karimi R, Tornling G, Grunewald J, et al. Cell recovery in bronchoalveolar lavage fluid in smokers is dependent on cumulative smoking history. PLoS One 2012; 7:e34232.
  27. Chang GC, Wu CL, Pan SH, et al. The diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures. Chest 2004; 125:541.
  28. Zompi S, Couderc LJ, Cadranel J, et al. Clonality analysis of alveolar B lymphocytes contributes to the diagnostic strategy in clinical suspicion of pulmonary lymphoma. Blood 2004; 103:3208.
  29. Phadke SM, Chini BA, Patton D, Goyal RK. Relapsed non-Hodgkin's lymphoma diagnosed by flexible bronchoscopy. Pediatr Pulmonol 2002; 34:488.
  30. Poletti V, Romagna M, Allen KA, et al. Bronchoalveolar lavage in the diagnosis of disseminated lung tumors. Acta Cytol 1995; 39:472.
  31. Lower EE, Baughman RP. Pulmonary lymphangitic metastasis from breast cancer. Lymphocytic alveolitis is associated with favorable prognosis. Chest 1992; 102:1113.
  32. Levy H, Horak DA, Lewis MI. The value of bronchial washings and bronchoalveolar lavage in the diagnosis of lymphangitic carcinomatosis. Chest 1988; 94:1028.
  33. Maldonado F, Parambil JG, Yi ES, et al. Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage. Eur Respir J 2009; 33:1361.
  34. De Lassence A, Fleury-Feith J, Escudier E, et al. Alveolar hemorrhage. Diagnostic criteria and results in 194 immunocompromised hosts. Am J Respir Crit Care Med 1995; 151:157.
  35. Heldt GH, Deubner DC. The beryllium bronchoalveolar lavage lymphocyte proliferation test: indicator of beryllium sensitization, inflammation or both? Inhal Toxicol 2015; 27:262.
  36. Jain P, Sandur S, Meli Y, et al. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest 2004; 125:712.