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Role of bronchoalveolar lavage in diagnosis of interstitial lung disease

INTRODUCTION

Bronchoalveolar lavage (BAL) is a minimally invasive diagnostic technique that provides insights into immunologic, inflammatory, and infectious processes occurring at the alveolar level. This topic will review the general utility of BAL in the setting of interstitial lung disease (ILD) and describe the BAL profiles of common interstitial processes [1]. The technique of BAL is 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".)

CONSTITUENTS OF BAL IN ILD

Changes in the relative and absolute quantities of cells in BAL fluid have been described in a variety of lung diseases. BAL findings may be sufficiently different in selected lung diseases to help narrow the differential diagnosis (table 1), and, on occasion, to suggest or confirm a particular diagnosis (table 2) [1-4]. In BAL fluid obtained from healthy, non-smoking adults without lung disease, only small numbers of lymphocytes, neutrophils, and eosinophils accompany the predominant population of alveolar macrophages (table 3A-C). In contrast, some diseases may be associated with one of the following abnormal cellular patterns, which may therefore be diagnostically useful:

  • Lymphocyte predominant (usually greater than 20 percent of the white cells) (table 4). The ratio of CD4 to CD8 lymphocytes may permit further definition of specific processes (table 5) [2].
  • Neutrophil predominant (usually greater than 5 percent of the white cells) (table 6)

  • Eosinophil predominant (usually greater than 5 percent of the white cells) (table 7)

BAL IN SPECIFIC INTERSTITIAL DISEASES

BAL is diagnostic primarily in the setting of malignancy or opportunistic infection, and occasionally reveals findings in other disorders that are sufficiently specific to obviate further evaluation (table 2) [1]. However, BAL findings are more frequently consistent with a given condition, rather than being pathognomonic. For this reason, we generally do not pursue BAL for the diagnosis of ILD unless malignancy or opportunistic infection is likely, or a transbronchial biopsy is being performed to obtain diagnostic tissue specimens.
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