Eur Aespir J 1989, 2, 561-585 TASK GROUP REPORT Technical recommendations and guidelines for bronchoalveolar lavage (BAL) Report of the European Society of Pneumology Task Group on BAL Edited by: H. Klech* and W. Pohl This group report was developed jointly by: Further Contributors: U. Costabel (Essen), C. Dane! (Paris), P. Haslam (London), W. Bassett (Paris), R. Baughman (Cincinnati), G. Huchon T. Higgenbottam (Cambridge), H. Klech (Vienna), W. Pohl. (Paris). G. Koenig (Munich), T. Izurni (Kyoto), W. Merill (Vienna), S. Rennard (Omaha), G. Rossi (Genova), M. Rust, (New Haven), W. Petcrmann (Kiel), M. Perrin-Fayolle (Lyon), (Frankfurt), G. Semenzato (Padova). M. Pirozynski (Warsaw), H. Reynolds (Hershey), M. Schmidl (Wuerzburg), M. Schweissfurth (Gelsenk), Y. Sibille (Brussels), H. Teschler (Essen). A. Venet (Paris). Contents Fiberbronchoscopy (H. Klech. W. Pohl) Flow Cytometry (P. Haslam, M. Rust) Premedication Principle of flow cytometry Local Anesthesia Preparation of samples Current applications with BAL fluid Safety of BAL (H. Klech) Non cellular components (W. Pohl, H. Klcch, W. Merrill, Site of lavage (U. Costabel. P. Haslam, G. Koenig, S. Rennard, Y. Sibille) H. Teschler) Origin of soluble components Quantification of epithelial lining fluid Sampling (G. Rossi, P. Haslam) Concentration steps Characterisation of immunoassays for BAL The fluid to be used to perform lavage General recommendations Ways to instill and recover the fluid Summary Volumes of fluid to be used Should the first aliquot be processed separately Dusts and miner als (P. Haslam. H. Klech) Mucus filtration Cytological appearences of particles Total and differential cell counts (U. Costabel, H. Klech, Mineralogical analysis of dust particles S. Rennard) Quantification of particles BAL and asbestos related malignancies Total cell counts Cytocentrifuge preparations E lectron microscopic a.nalysis (C. Danel, F. Basset) Cell smears Millipore filter preparations BAL in lung cancer and other malignancies (H. Klech, Counting of cell differentials P. Haslam) Techniques for infectious agents (C. Dane!, G. Huchon, Definition of normal values, expression of results S. Rennard, M. Rust, A. Venet) (U. Costabel, H. Klech) Safety of BAL in irnmunocompromised patients Monoclonal assays (G. Semenzato, U. Costabel, G. Rossi) Pneumocystis carinii Cytomegalo and other viruses Handling of cell suspensions Mycobacteria Analysis by immunofluorescence Fungi Double fluorescence analysis Bacteria Analysis by immunocytochemistry Other microorganisms Reagents to differentiate monouclear cells Technical recommendations in immunocompromised patients 562 H. KLECH, W. POHL BAL in lung transplantation (T. Higgenbottam) Freezing and storage of BAL constituents (G. Rossi, G. Semenzaro) Potential applications of BAL in HLTX Diagnosis of opportunistic lung infection Storage and freezing of BAL fluid Diagnosis of rejection Storage and freezing of BAL cell suspensions Determination of lymphocyte reactivity Technique of BAL in HLTX patients Transport of BAL fluid (M. Rust, W. Petermann, Differential cell count and immunochemistry U. Costabel, H. Teschler) Studies of lymphocyte reactivity Spontaneous proliferation Analysis of cells Non specific activation of T cells Analysis of supematant Secondary allogenic lymphocyte proliferation Infectious agents Cell mediated lympholysis (CML) --------- Bronchoalveolar lavage (BAL) is a useful and safe acceptance of BAL as an established clinical tool. In method for sampling cellular and biochemical compo­ order to develop reasonable technical guidelines on how nents from bronchoalveolar lung units. Today, BAL is to perform and process BAL as well as to make clini­ performed in centres worldwide, and its role as an cal recommendations about the value and indications of important research tool is unquestioned [1, 2]. Although BAL, the Executive Committee of the European Soci­ a large number of investigators have described the clini; ety of Pneumology (SEP) set up a European Task cal usefulness of BAL in various diseases of the lung Group on BAL. This is the first report of the group, and have suggested the value of BAL for diagnosis and focusing on technical guidelines and recommendations monitoring, there is no general consensus whether, and for performance of BAL and processing the material. to what extent, BAL can be used clinically for routine In the past year members of the group have tried to diagnostic purposes. In particular, differences in tech­ collect and review the available literature. Personal ex­ nical procedures and in processing the BAL fluid so far periences of group members are also included. appear to be one of the main obstacles to universal Fibt>rl.lronchoscopy Bronchoalveolar lavage (BAL) is performed predomi­ can cause trauma, contamination with blood and loss of nantly under local anaesthesia with a flexible fiberscope. instilled fluid. A recent international survey has shown that about 93% of centres which perform BAL use local rather [han general anaesthesia [3). However, BAL performed un­ Premedication der general anaesthesia appears to yield similar results [4]. BAL can also be performed safely in patients with Most centres use sedating compounds such as diaze­ an oral or nasotracheal tube in position by inserting the pam or meperidine together with atropine as premedi­ fiberscope through the tube, provided its diameter is cation for fiberscopy. Atropine is intended to minimize greater than 6 mm. Mechanical ventilation can be con­ vasovagally induced bradycardia as well as to decrease tinued throughout the entire procedure if necessary. airway secretion. The influence of atropine on the yield Most centres use a standard size fiberscope with a of BAL cells has only been preliminarily addressed [5] sucking channel of about 2 mm. Although small diame­ demonstrating that atropine pretreated patients have a ter fiberscopes can operate in more distal segments of higher BAL return in comparison to a control group. the bronchial system, the risk of bronchial collapse in­ The effect of atropine on the composition of noncellu­ creases. On the other hand when using large diameter lar components of BAL remains unclear. fiberscopes the instrument cannot be advanced as far and more bronchial than alveolar constituents are found Local anaesthesia in the BAL samples. Optimal recovery is accomplished by occluding the bronchial lumen with the broncho­ Local anaesthesia is usually accomplished by local scope. The tip of the bronchoscope is therefore ad­ application of lidocaine: 1) spray aerosol for treatment vanced into a bronchial segment until a wedge position of the nasal, oral, pharyngeal and laryngeal area; 2) is reached. Coughing should be prevented because it direct instillation via the bronchoscope for anaesthesia of the trachea, carinae and bronchi. Lidocaine present in the airways should be removed prior to instilla­ * H. Klech, 2nd Medical Dept, Wilhelminenspit.al, Mon!leartstrasse 37, A-1160 Vienna, Austria. tion of the lavage fluid, since it may influence cell Request for reprints to H. Klech. viability. TECHNICAL RECOMMENDATIONS AND GUIDELINES FOR BAL 563 Safety of BAL BAL is a safe procedure. Minor side-effects include instilled fluid in the middle lobe, is not altered when coughing during lavage, fever and chills some hours measured 24 h after BAL [16). after lavage (which can usually be treated by use of Supplemental oxygen delivery, ear-oximetry and simple antipyretics), transient alveolar infiltration in the ECG-monitoring are strongly advised in patients with dependent lung segment 24 h after the procedure, tran­ severe underlying disease or other critical condition. sient deterioration of lung function parameters such as Patients with mild asthma have been successfully lav­ vital capacity, forced expiratory volume in one second aged [10]. However, patients with a history of bron­ (FEV 1), and decrease of arterial oxygen tension (Pao:J. chial asthma should be handled with special caution and Consequences of saline lavage are expressed more in careful monitoring is advised [9, 17]. The following are patients with underlying pulmonary diseases than in recomended, healthy volunteers. Most of the reported side-effects are 1. Supplemental oxygen with a nasal prong should be closely related to endoscopic technique, location and administered throughout the entire procedure; extent of lavaged lung area, and the volume and tem­ 2. Premedication with aerosolized beta-agonists; perature of instilled fluid (summary in table 1). Lung 3. Ear-oximetry and ECG-monitoring. epithelial permeability, when using a volume of 250 ml Table 1. - Consequences and side effects of BAL Side-effect Occurrence Reference Alveolar infiltration Rarely seen* [6, 7] Crackles Within 24 h over dependent areasU (8, 9] Wheezing In hyperreactive patients up to 1-2 weeks [101 Fever 10-30%, some hours after BAL** [6, 7, 11] Lung function unpailmenL Transient decrease of FEY , VC, PEF, Pao •• s.ss [9, 11-15) 1 2 No effect on lung epithelial permeability 24 h after BAL [16] Transient rise of Pa<.: o patients with COPIJS·SS [4] 2 ut Bronchospasm Rarely in normoreactive, more frequently in hyperreactive patients [6, 9, 10] Pneumothorax Only when transbronchial biopsies are performed Bleeding Insignificant [6] •: risk increases with size of instilled lavage fluid volume and numbers of lavaged segments; ••: risk increases with volume of instilled lavage volume; S: more likely in hyperreactive patients or in patients with severe tmderlying infiltrative lung diseases;