Clinical Microscopy

BRONCHOALVEOLAR LAVAGE

Bronchoalveolar Lavage

Provides a method for obtaining cellular and microbial information from the lower respiratory tract.
Saline infused by bronchoscope mixes with the bronchial contents and is aspirated for examination and culture
Useful in evaluating immunocompromised patients, interstitial lung disease, airway diseases, and suspected alveolar
hemorrhage

Specimen preparation
Separated into two sampes:
1. Bronchial sample- first aliquot instilled and recovered
2. Alveolar sample- consists of subsequent 3 to 5 aliquots, which are instilled and recovered.
o Specimens should be analyzed immediately. Cell counts should be performed within 1 hour
Specimen analysis

Hematology:
Color
Clarity
Presence of clot
Volume
Cell counts
Differential counts
WBC count:
May be diluted using Unopette diluting system
Diluent: 1/100 ammonium oxalate or 1/20 glacial acetic acid (lyses the RBC)
When the RBCs have lysed and the solution is clear, the fluid is plated on a hemocytometer. Allow to settle for 5 minutes.
Count in 18 squares (both sides of the hemocytometer). Average of the two sides is calculated.

WBC/cmm=

RBC count
Diluted with isotonic saline
Plated on the hemocytometer and allowed to settle for 5 minutes
Both sides of the hemocytometer are counted

averagenumber of cells dilutionfactpr 10

9 squares

RBC/cmm=

number of cells dilutionfactor 10

number of squares counted

Differential slides are prepared by cytocentrifugation using routine procedures, and at least 300 cells but often 500 to 1000 cells are
counted and classified
o Ventilator-associated pneumonia- useful for quantitative or semiquantitative cultures
Diagnostic of the infection if the organism is identified
Detect infection and for monitoring antibiotic therapy
o Pneumocystis carinii in immunocompromised patient- cup-shaped; with characterstic amorphous material seen microscopically
o Cryptococcus neoformans- opportunistic pathogen in patients with AIDS.
diagnosis can be made by demonstrating a positive cryptococcl antigen in respiratory specimens exhibiting yeast cells that
morphologically resemble C. neoformans.
The extent of infection correlates with the antigen titer
o Cytologic studies include observing sulphur granules (actinomycetes), hemosiderin-laden macrophages, Langerhans cells,
cytomegalic cells, fat droplets seen in fat embolism with an Oil red stain, and lipid-laden alveolar macrophages using a Sudan III
stain.
o Dust particle inclusion- indicative of pneumoconioces or asbestos exposure
o

GLT

Cell

Macrophage

Lymphocytes

N
.
V
.
5
6
8
0
%
1
5
%

Clinical Microscopy
BRONCHOALVEOLAR LAVAGE
- Clinical Significance

CELLS SEEN IN BAL

Often containing a variety of phagocytized material

Increased in interstitial lung disease, drug reactions, pulmonary lymphoma,

nonbacterial infections

Most frequently seen

CD4/CD8 lymphocytes- defines disease process

Elevated: sarcoidosis
connective tissue disorders
Normal: tuberculosis
malignancies
Low:
hypersensitivity pneumonitis
Silicosis
drug-induced disease
HIV

Neutrophils

<
3
%

Primary granulocyte seen

Elevated: Cigarette smokers

Eosinophils

RBC

1
2
%

Diffuse alveolar damage

Elevated: Asthma

Drug-induced lung disease

Infections(parasitic, mycobacterial, or fungal)
Hypersensitivity
Pneumonitis
Eosinophilic pneumonia

Phagocytosed

Hemosiderin-

Alveolar hemorrhage within 48 hours

rbc
-

Bronchopneumonia
Toxin exposure

Alveolar hemorrhage greater than 48 hours

laden

Ciliated
columnar
bronchial
epithelial cells

In bronchial
wash specimens
In bronchial
lavage specimens
- Fungal
Elements and
viral inclusions
-

More numerous because of the more vigorous washing technique

Pneumocystic carinii, Toxoplasma gondii, Cryptococcus neoformans,

Histoplasma capsulatum, Mycobacterium tuberculosis, Mycoplasma
pneumoniae,

Influenza A and B virus, respiratory syncytial virus

4
1
7
%

GLT

Clinical Microscopy
BRONCHOALVEOLAR LAVAGE
-

GLT