Role of bronchoalveolar lavage in diagnosis of interstitial lung disease
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
- Section Editors
- Kevin R Flaherty, MD, MS
Kevin R Flaherty, MD, MS
- Section Editor — Interstitial Lung Disease
- Associate Professor of Medicine
- University of Michigan Health System
- Praveen N Mathur, MB, BS
Praveen N Mathur, MB, BS
- Section Editor — Interventional Pulmonology
- Professor of Clinical Medicine
- Indiana University School of Medicine
Bronchoalveolar lavage (BAL) is a minimally invasive procedure performed during flexible bronchoscopy to obtain a sample of alveolar cells. Analysis of BAL cell counts, cytology, and culture provides insights into immunologic, inflammatory, neoplastic, and infectious processes occurring at the alveolar level.
This topic will review the role of BAL in the setting of interstitial lung disease (ILD) and the cell profiles found in common interstitial lung diseases [1,2]. The technique of BAL and the analysis of lavage fluid are discussed separately, as is the overall approach to the patient with ILD. (See "Basic principles and technique of bronchoalveolar lavage" and "Approach to the adult with interstitial lung disease: Diagnostic testing".)
CONSTITUENTS OF BAL IN ILD
In the evaluation of interstitial lung disease, bronchoalveolar lavage (BAL) findings are typically nonspecific, being consistent with or suggestive of a given condition, rather than pathognomonic [3,4]. In patients with an acute presentation of dyspnea and interstitial opacities, BAL is sometimes helpful to identify alveolar hemorrhage, malignancy, or opportunistic infection (table 1) .
When BAL fluid is obtained from healthy adults, only small numbers of lymphocytes, neutrophils, and eosinophils accompany the predominant population of alveolar macrophages (table 2A-C). In patients with interstitial lung disease (ILD), a variety of changes in the relative and absolute numbers of individual cell constituents have been described. Usually, these changes are nonspecific, but occasionally, the pattern is sufficiently characteristic to guide the differential diagnosis (table 3), or rarely, to confirm the diagnosis of a particular ILD (table 1) [1,5-8].
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- CONSTITUENTS OF BAL IN ILD
- LYMPHOCYTIC BAL
- Hypersensitivity pneumonitis
- MIXED CELLULARITY BAL
- Idiopathic pulmonary fibrosis
- Nonspecific interstitial pneumonia
- Cryptogenic organizing pneumonia
- Connective tissue diseases
- Drug-induced pulmonary disease
- EOSINOPHILIC BAL
- Acute eosinophilic pneumonia
- Chronic eosinophilic pneumonia
- Eosinophilia and infection
- HEMORRHAGIC BAL
- OTHER USEFUL BAL FINDINGS
- Chronic microaspiration
- Malignant cells
- Pulmonary Langerhans cell histiocytosis
- Pulmonary alveolar proteinosis
- SUMMARY AND RECOMMENDATIONS