A saline wash of the airways (Broncho) and air
sacs (alveolar) for recovery of inflammatory cells.
Indicated for recovery of cells for cytologic analysis of inflammatory processes such as
- Interstitial lung diseases
- Fungal pneumonias
- Unexplained chronic cough
Not indicated for
- Acute pneumonia or pleuropneumonia.
- Acute viral infections.
- Bronchitis caused by bacterial infection.
Contraindicated in patients with
- Severe coughing not alleviated by prior administration of bronchodilator
(e.g. 450 µg (5 puffs) of albuterol)
- Dyspnea (labored breathing) or cyanosis
- Cardiac arrhythmias
- Tachycardia (Heart rate > 60 beats per minute)
- Bleeding tendencies
Equipment for BAL
- Two 60cc syringes filled with dilute lidocaine (0.3%) without
- Bronchoalveolar lavage tube (3 meters length, 11 mm outside diameter,
Bivona, Top) or endoscope (> 2.5 meters length, 11-14 mm O.D, Bottom)
|BAL tube with
insets showing open end and inflation port (left) and inflatable cuff (right)
- Bottle (500 cc) of sterile physiological saline solution, warmed to body
- Vented solution administration set (from saline bottle to stopcock).
- Inflation bulb and short length tubing, to pressurize the saline bottle.
- Sterile lubricant.
- 10ml syringe to inflate cuff on BAL tube.
- Vacuum pump with collection bottle or large volume syringes
(>60cc) to aspirate BAL fluid.
- Connect equipment as shown in diagram.
|Diagram of BAL setup
- Place a small amount of sterile lubricant on the last
5-10 cm of BAL tube.
- Pass BAL tube or endoscope through ventral meatus into nasopharynx.
|Placement of BAL tube through nasal
- Inject 30cc of dilute lidocaine onto the vocal folds / epiglottis region.
- Advance BAL tube into the trachea, then quickly, but gently, to the point
- resistance and bending of the tube is felt (about 2-2.5 meters passed).
- Inflate cuff of BAL tube with air (10 ml).
- Infuse 250 ml of saline into BAL tube as rapidly as you can.
- Aspirate gently and slowly using a vacuum pump (-10 cm H2O
pressure) or a series of large volume syringes.
- Repeat infusion of 250 ml of saline, and aspirate again.
- Expect 60 100 ml return from the first 250 ml aliquot, and 120-200
ml from the second.
Handling BAL Specimens
- Pour BAL fluid into a couple of large EDTA tubes.
- Centrifuge the sample at 600 x g (fastest tabletop centrifuge speed) for
- Pour off supernatant thoroughly, leaving small pellet stuck to bottom.
- Mix pellet with saline that remains (i.e. about 1/10 ml).
- Prepare thin smears using the blood smear technique.
- DRY IMMEDIATELY wave your hands, use fan, etc
- Stain with Diff-Quik, WrightGiemsa, May-Gruenwald, or similar
- Check the quality of the smear before discarding BAL fluid or sending to
- There should be a layer of cells, about ½ as thick as a typical blood
- To transport BAL samples from the field, pour samples into EDTA tubes or
dilute 50:50 with grain alcohol or Vodka (100 Proof) and transport in clot tubes. Don't
drink and drive!
Keep fluid samples cool or refrigerate until
ready for staining.