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].
As examples:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kilinç G, Kolsuk EA. The role of bronchoalveolar lavage in diffuse parenchymal lung diseases. Curr Opin Pulm Med 2005; 11:417.
- 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.
- Singh K, Khan S, Agarwal S, et al. The performance of high-volume bronchoalveolar lavage for the evaluation and diagnosis of interstitial lung disease. Ann Thorac Surg 2014; 97:720.
- Lee W, Chung WS, Hong KS, Huh J. Clinical usefulness of bronchoalveolar lavage cellular analysis and lymphocyte subsets in diffuse interstitial lung diseases. Ann Lab Med 2015; 35:220.
- 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.
- Meyer KC. The role of bronchoalveolar lavage in interstitial lung disease. Clin Chest Med 2004; 25:637.
- Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax 2008; 63 Suppl 5:v1.
- Capelozzi VL, Faludi EP, Balthazar AB, et al. Bronchoalveolar lavage improves diagnostic accuracy in patients with diffuse lung disease. Diagn Cytopathol 2013; 41:1.
- Ohshimo S, Bonella F, Cui A, et al. Significance of bronchoalveolar lavage for the diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2009; 179:1043.
- Lynch DA, Rose CS, Way D, King TE Jr. Hypersensitivity pneumonitis: sensitivity of high-resolution CT in a population-based study. AJR Am J Roentgenol 1992; 159:469.
- Semenzato G, Bjermer L, Costabel U, et al. Clinical guidelines and indications for bronchoalveolar lavage (BAL): extrinsic allergic alveolitis. Eur Respir J 1990; 3:945.
- Drent M, Mansour K, Linssen C. Bronchoalveolar lavage in sarcoidosis. Semin Respir Crit Care Med 2007; 28:486.
- Winterbauer RH, Lammert J, Selland M, et al. Bronchoalveolar lavage cell populations in the diagnosis of sarcoidosis. Chest 1993; 104:352.
- Danila E, Norkūniene J, Jurgauskiene L, Malickaite R. Diagnostic role of BAL fluid CD4/CD8 ratio in different radiographic and clinical forms of pulmonary sarcoidosis. Clin Respir J 2009; 3:214.
- Poulter LW, Rossi GA, Bjermer L, et al. The value of bronchoalveolar lavage in the diagnosis and prognosis of sarcoidosis. Eur Respir J 1990; 3:943.
- Costabel U, Bross KJ, Guzman J, et al. Predictive value of bronchoalveolar T cell subsets for the course of pulmonary sarcoidosis. Ann N Y Acad Sci 1986; 465:418.
- Verstraeten A, Demedts M, Verwilghen J, et al. Predictive value of bronchoalveolar lavage in pulmonary sarcoidosis. Chest 1990; 98:560.
- Bjermer L, Rosenhall L, Angström T, Hällgren R. Predictive value of bronchoalveolar lavage cell analysis in sarcoidosis. Thorax 1988; 43:284.
- Okada M, Takahashi H, Nukiwa T, et al. Correlative analysis of longitudinal changes in bronchoalveolar lavage, 67gallium scanning, serum angiotensin-converting enzyme activity, chest X-ray, and pulmonary function tests in pulmonary sarcoidosis. Jpn J Med 1987; 26:360.
- Israel-Biet D, Venet A, Chrétien J. Persistent high alveolar lymphocytosis as a predictive criterion of chronic pulmonary sarcoidosis. Ann N Y Acad Sci 1986; 465:395.
- Ceuppens JL, Lacquet LM, Mariën G, et al. Alveolar T-cell subsets in pulmonary sarcoidosis. Correlation with disease activity and effect of steroid treatment. Am Rev Respir Dis 1984; 129:563.
- Watters LC, Schwarz MI, Cherniack RM, et al. Idiopathic pulmonary fibrosis. Pretreatment bronchoalveolar lavage cellular constituents and their relationships with lung histopathology and clinical response to therapy. Am Rev Respir Dis 1987; 135:696.
- Haslam PL, Turton CW, Heard B, et al. Bronchoalveolar lavage in pulmonary fibrosis: comparison of cells obtained with lung biopsy and clinical features. Thorax 1980; 35:9.
- Haslam PL, Turton CW, Lukoszek A, et al. Bronchoalveolar lavage fluid cell counts in cryptogenic fibrosing alveolitis and their relation to therapy. Thorax 1980; 35:328.
- Turner-Warwick M, Haslam PL. The value of serial bronchoalveolar lavages in assessing the clinical progress of patients with cryptogenic fibrosing alveolitis. Am Rev Respir Dis 1987; 135:26.
- Rudd RM, Haslam PL, Turner-Warwick M. Cryptogenic fibrosing alveolitis. Relationships of pulmonary physiology and bronchoalveolar lavage to response to treatment and prognosis. Am Rev Respir Dis 1981; 124:1.
- Merrill WW, Reynolds HY. Bronchial lavage in inflammatory lung disease. Clin Chest Med 1983; 4:71.
- Fireman E, Vardinon N, Burke M, et al. Predictive value of response to treatment of T-lymphocyte subpopulations in idiopathic pulmonary fibrosis. Eur Respir J 1998; 11:706.
- Veeraraghavan S, Latsi PI, Wells AU, et al. BAL findings in idiopathic nonspecific interstitial pneumonia and usual interstitial pneumonia. Eur Respir J 2003; 22:239.
- Tabuena RP, Nagai S, Tsutsumi T, et al. Cell profiles of bronchoalveolar lavage fluid as prognosticators of idiopathic pulmonary fibrosis/usual interstitial pneumonia among Japanese Patients. Respiration 2005; 72:490.
- Kinder BW, Brown KK, Schwarz MI, et al. Baseline BAL neutrophilia predicts early mortality in idiopathic pulmonary fibrosis. Chest 2008; 133:226.
- Petrosyan F, Culver DA, Reddy AJ. Role of bronchoalveolar lavage in the diagnosis of acute exacerbations of idiopathic pulmonary fibrosis: a retrospective study. BMC Pulm Med 2015; 15:70.
- Wallaert B, Rossi GA, Sibille Y. Clinical guidelines and indications for bronchoalveolar lavage (BAL): collagen-vascular diseases. Eur Respir J 1990; 3:942.
- Costabel U, Uzaslan E, Guzman J. Bronchoalveolar lavage in drug-induced lung disease. Clin Chest Med 2004; 25:25.
- Swartz J, Stoller JK. Acute eosinophilic pneumonia complicating Coccidioides immitis pneumonia: a case report and literature review. Respiration 2009; 77:102.
- Ong RK, Doyle RL. Tropical pulmonary eosinophilia. Chest 1998; 113:1673.
- Lichtenberger JP 3rd, Digumarthy SR, Abbott GF, et al. Diffuse pulmonary hemorrhage: clues to the diagnosis. Curr Probl Diagn Radiol 2014; 43:128.
- Kindt GC, Weiland JE, Davis WB, et al. Bronchiolitis in adults. A reversible cause of airway obstruction associated with airway neutrophils and neutrophil products. Am Rev Respir Dis 1989; 140:483.
- Grebski E, Hess T, Hold G, et al. Diagnostic value of hemosiderin-containing macrophages in bronchoalveolar lavage. Chest 1992; 102:1794.
- Costabel U, Guzman J, Bonella F, Oshimo S. Bronchoalveolar lavage in other interstitial lung diseases. Semin Respir Crit Care Med 2007; 28:514.
- Sherman JM, Winnie G, Thomassen MJ, et al. Time course of hemosiderin production and clearance by human pulmonary macrophages. Chest 1984; 86:409.
- Golde DW, Drew WL, Klein HZ, et al. Occult pulmonary haemorrhage in leukaemia. Br Med J 1975; 2:166.
- Drew WL, Finley TN, Golde DW. Diagnostic lavage and occult pulmonary hemorrhage in thrombocytopenic immunocompromised patients. Am Rev Respir Dis 1977; 116:215.
- Kahn FW, Jones JM, England DM. Diagnosis of pulmonary hemorrhage in the immunocompromised host. Am Rev Respir Dis 1987; 136:155.
- Costabel U, Guzman J. Bronchoalveolar lavage in interstitial lung disease. Curr Opin Pulm Med 2001; 7:255.
- Corwin RW, Irwin RS. The lipid-laden alveolar macrophage as a marker of aspiration in parenchymal lung disease. Am Rev Respir Dis 1985; 132:576.
- Lauque D, Dongay G, Levade T, et al. Bronchoalveolar lavage in liquid paraffin pneumonitis. Chest 1990; 98:1149.
- Silverman JF, Turner RC, West RL, Dillard TA. Bronchoalveolar lavage in the diagnosis of lipoid pneumonia. Diagn Cytopathol 1989; 5:3.
- Spatafora M, Bellia V, Ferrara G, Genova G. Diagnosis of a case of lipoid pneumonia by bronchoalveolar lavage. Respiration 1987; 52:154.
- Pujol JL, Barnéon G, Bousquet J, et al. Interstitial pulmonary disease induced by occupational exposure to paraffin. Chest 1990; 97:234.
- Rennard SI. Bronchoalveolar lavage in the diagnosis of cancer. Lung 1990; 168 Suppl:1035.
- Lower EE, Baughman RP. Pulmonary lymphangitic metastasis from breast cancer. Lymphocytic alveolitis is associated with favorable prognosis. Chest 1992; 102:1113.
- Cadranel J, Wislez M, Antoine M. Primary pulmonary lymphoma. Eur Respir J 2002; 20:750.
- 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.
- Baqir M, Vassallo R, Maldonado F, et al. Utility of bronchoscopy in pulmonary Langerhans cell histiocytosis. J Bronchology Interv Pulmonol 2013; 20:309.
- 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.
- 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