SCHOOL OF MEDICINE

Department of Medicine

Pulmonary, Critical Care, Sleep & Occupational Medicine

Bronchoalveolar Lavage Laboratory

Protocol for Bronchoalveolar Lavage | Sample Preparations | Instructions to Clients

The lab is located at Walther Hall on the IUPUI Campus.

BAL specimens are processed Monday through Friday from 8:00 am - 5:00 pm. BAL specimens can be received after 8:00 am, and no later than 4:00 pm. Specimens are not received or processed by the BAL lab during weekend hours (Sat & Sun). The BAL lab will not accept specimens that are more than 18 hours old. Notify the BAL lab as soon as possible about an anticipated specimen, i.e. if a patient is scheduled for a BAL ahead of time, please notify us (at least 24 hours notice is preferred). In addition, BAL specimens will not be processed on the following observed holidays:

  • New Year's Day
  • Martin Luther King, Jr. Day
  • Memorial Day
  • Independence Day
  • Labor Day
  • Thanksgiving Day
  • Day after Thanksgiving
  • Christmas Eve Day
  • Christmas Day

Note: If the holiday falls on a weekend, the following Monday will be observed. Contact the Pulmonary Office at 317-278-2253 if there is uncertainty as to holiday dates.


Protocol for Bronchoalveolar Lavage

Although there is no agreed upon or standardized way to perform bronchoalveolar lavage, we have had extensive experience and validation of the following protocol:

  1. Bronchoalveolar lavage is performed prior to any biopsies, brushes, or manipulations of the airway.
     
  2. The bronchoscope is wedged into a subsegment of the middle lobe, anterior segment of a lower lobe, or the most affected area. The suction is turned down to prevent collapse of the airways during suctioning. Typically, this is between 40-80 psi (green on the low wall suction pressure indicator).
     
  3. The trap is changed to a fresh, clean trap.
     
  4. Three (3) 50cc aliquots of either saline or Plasmalyte are used.
     
  5. After each 50 cc is instilled, wait a few seconds to dwell and apply constant suction for several seconds (20 seconds typically) until return of the frothy surfactant-rich fluid stops. The next aliquot is instilled and suction applied, repeat for all three aliquots.
     
  6. Once all fluid is collected, the trap is removed and put to the side, preferably on ice. The trash trap or hook up directly to the wall suction is then reapplied and bronchoscopy is performed as needed for biopsies and other procedures.
     
  7. At no time is the bronchoalveolar lavage fluid added to bronchial washings or "trash trap" (is fine for cytology, but not us). The BAL is then sent our lab on ice by courier.
     
  8. Although return on bronchoalveolar lavage is quite variable (usually 40-60% of volume instilled), we ideally should receive 30 cc of fluid. The remainder of the fluid could go to cytology or microbiology for culture.
     
  9. Sending less than 15 cc of bronchoalveolar lavage fluid is not recommended due to inability to validate the results with the low number of cells in this amount of fluid.
     
  10. We process the specimen to optimize cell differentials and perform T cell subtyping and other special phenotypic stains. This processing is performed exclusively for evaluation of interstitial and immunologic lung diseases when they are high on the differential. Sample should also be sent to cytology or microbiology as deemed clinically appropriate.

Contact Information
If there are any questions, please contact Patricia Smith, Bronchoalveolar Lavage Coordinator, at 317-278-2253.


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Sample Preparations

 

BAL - Healthy Non-Smoker BAL from a healthy non-smoker with over 95% alveolar macrophages
BAL from a smoker with interstitial lung disease, note many carbonaceous alveolar macrophages BAL - Smoker with Interstitial Lung Disease
BAL - Acute Eosinophilic Pneumonia BAL from a patient with acute eosinophilic pneumonia (>40% eosinophils in the BAL, only 2% in blood). The eosinophils are bi-lobed with pink cytoplasm.

BAL from a patient with sarcoidosis. An intense CD4+ lymphocytic alveolitis is seen. T cell CD4/CD8 subtypes are done by flow cytometry on specimens with more than 15% T cells.

Abstract of this study on PubMed

BAL - Sarcoidosis

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Instructions to Clients

These instructions are for all physicians, clerical, nursing, laboratory or other staff that are involved in the preservation, transportation, and/or collection of bronchoalveolar lavage specimens.

Notification

  1. The BAL lab should be contacted about a BAL request as soon as the procedure is scheduled. At least 24 hours notice is preferable for outpatients, and one hour notice for inpatients.

  2. The BAL supervisor, Pat Smith, should be notified by calling the lab office at 317-988-3811. If Pat Smith is not available, please leave the information with the secretary. The following information should be provided:
     
    • Name of patient
    • Hospital and medical record number
    • Name and pager number of requesting physician
    • Date of BAL
    • Approximate time that the BAL will be delivered
    • Tentative diagnosis

  3. BAL Request Forms
     
    • A BAL Request Form must always be completed in full and sent with the BAL specimen. Please print legibly. The time the sample was collected must be reported. For "other" diagnosis and drug effects, please specify type. Indicate all three volumes 1) volume instilled 2) volume returned 3) volume given to BAL lab (necessary since aliquots are sometimes removed and sent to other labs before sample receipt). If more than one BAL specimen is sent for the same patient, please indicate the site of the BAL on both the specimen container and the request form.

    • Place the patient ID label where indicated on the request form. If a label is not available, a legibly printed name and MRN will be acceptable.

    • If the BAL request forms are not available or are running low in your area, please contact our office as soon as possible. If a BAL request form is needed immediately but is not available, please request that a copy be faxed to the requesting office. This should then be completed and sent with the specimen.

    • We must receive written notification (a BAL Request Form). If for some reason a BAL Request Form is not sent with the BAL specimen, one must be sent to our office within 15 days. Results will not be sent until written consent has been sent.

    • Whenever "other" is selected under suspected diagnosis, the other suspected diagnosis should be listed.

    • A pager or contact number should always be listed in case there are any questions or missing information.

Specimen Labeling

The specimen label should always contain:

  • Patient name
  • Hospital name and Medical Record Number
  • Date of patient admission
  • All samples should be labeled as a potential biohazard and transported appropriately

Specimen Preservation / Transportation
  • The specimen should be placed in a plastic storage bag and accompanied with a completed BAL form.
  • The specimen should be stored in the refrigerator or on ice. DO NOT FREEZE. The sample should be transported on ice and always be delivered as soon as possible.
  • If the specimen is sent by courier, it is recommended that the client call ahead of time.


The specimen should be sent directly to the lab at:

Pulmonary Division - Bronchoalveolar Lavage Lab
980 W. Walnut St.
Walther Hall, Rm C440A
Indianapolis, IN 46202
Phone: 317-278-2253
Fax: 317-278-0027

Directions to our location

  • From I-65 exit onto Martin Luther King, turn right onto 11th St. (Oscar Robinson Blvd), turn left onto University Blvd, turn right onto West Walnut street. Walther Hall is on the right.
  • From I-70 merge onto I-65 north and exit onto Martin Luther King, turn right onto 11th St. (Oscar Robinson Blvd), turn left onto University Blvd, turn right onto West Walnut St. Walther Hall is on the right.
  • From Downtown go north on West St., go west (left) onto Michigan St., go north (right) onto University Blvd., turn left onto West Walnut St., Walther Hall is on the right.


The BAL lab telephone number (317-278-2253) should be given to the courier service in case the courier is having difficulty delivering the specimen.

Specimen Processing and Results

The BAL lab will be responsible for:

  • Processing the specimen by performing centrifugation, removing red cell contamination, preparing and staining cytopreps, and determining the cell differential.
     
  • Subtyping lymphocytes and determining the helper/suppressor ratio if the lymphocyte count is 15% or more by the cell differential count.

We also offer CD1a surface marker staining, hemosiderin staining, and oil red O staining (if requested and if the cytoprep is compatible with the diagnosis).

Suboptimal conditions and potential causes for sample rejection

  • BAL processed more than 24 hrs after specimen collection
  • BAL contains less than 1 x 106 cells
  • BAL < 20% of volume instilled
  • BAL contaminated with more than 10% epithelial cells

All bronchoalveolar lavage samples will be processed unless they are not properly identified with the patient name and ID number or arrive at the lab in subsatisfactory conditions (i.e., container not intact, sample frozen, sample > 20 hrs old).

Questions / Comments

Any questions, requests, complaints can be directed to the supervisor, Pat Smith, by calling 317-278-2253.


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