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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 8-11

Location of bronchoalveolar lavage in children


Department of Medical Services, Division of Pulmonology and Critical Care, Queen Sirikit National Institute of Child Health, Ministry of Public Health, Bangkok, Thailand

Date of Web Publication9-May-2019

Correspondence Address:
Natcha Sakrajai
Department of Medical Services, Division of Pulmonology and Critical Care, Queen Sirikit National Institute of Child Health, Ministry of Public Health, 420/8 Rajavithi Road, Rajatevee, Bangkok 10400
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/prcm.prcm_7_18

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  Abstract 


Background: Bronchoalveolar lavage (BAL) is a useful procedure in the diagnosis and treatment of several respiratory diseases. The right middle lobe or lingula is the preferred location of BAL in diffuse lung disease. The aim of this study was to determine the proper location of BAL in infants and children. Design: This was prospective, observational study at Queen Sirikit National Institute of Child Health between January and December 2017. Materials and Methods: Children, aged 1 month to 15 years, who underwent BAL were enrolled for this study. BAL was performed with the flexible bronchoscope under general anesthesia. The total instilled volume was generally 2–3 ml/kg, divided into 2–6 aliquots. The location of BAL was the most affected area in chest radiography. In diffuse lung disease, BAL was performed in all lobes. The volume and percentage of fluid recovered from various lobes were compared. Statistical Analysis: Statistical analysis was performed using SPSS version 23. The value of P < 0.05 was considered statistically significant. Results: A total of 66 patients with a median age of 1.6 years were enrolled. The total volume recovered was 20% of the instilled volume (interquartile range [IQR] 13.4, 31.8). The volume recovered from the right lung (23%, IQR 13.4, 32.58) was significantly higher than from the left lung (18.9%, IQR 12.5, 30, P = 0.019). There was no significant difference between volume recovered from various lobes. However, there was a trend toward higher volume recovered from the right lower lobe (RLL) (25%, IQR 13.1, 33.75). Conclusions: In infants and children, BAL performed in the right lung and RLL is associated with a higher volume recovered.

Keywords: Bronchoalveolar lavage, flexible bronchoscopy, pediatric bronchoscopy


How to cite this article:
Sakrajai N, Srisan P. Location of bronchoalveolar lavage in children. Pediatr Respirol Crit Care Med 2019;3:8-11

How to cite this URL:
Sakrajai N, Srisan P. Location of bronchoalveolar lavage in children. Pediatr Respirol Crit Care Med [serial online] 2019 [cited 2019 Nov 20];3:8-11. Available from: http://www.prccm.org/text.asp?2019/3/1/8/257934




  Introduction Top


Bronchoalveolar lavage (BAL) has been accepted as a valuable procedure in the diagnosis and treatment of airway and pulmonary diseases in adults and children.[1],[2],[3],[4] Generally, BAL is performed in the most affected site depending on the radiologically identified involved lobe. The right middle lobe (RML) or lingula is the preferred site in a patient with diffuse infiltration due to the easily accessible site with good volume recovered.[3],[4],[5],[6],[7],[8] Whereas the right lower lobe (RLL) is more accessible location for BAL in infants.[6] Regarding the amount of fluid and the number of aliquots that should be used in children, the technique is not fully standardized. In adult, the total instilled volume is between 100 and 300 ml, divided into 3–5 aliquots.[3] Several studies in children used 2–4 aliquots of the same volume as in adults: 10 ml for children <6 years of age and 20 ml for children over 6 years of age,[5] or 5–20 ml irrespective of the body weight and age. Others adjust instilled volume to body weight: Using 1 ml/kg/aliquot for three times in children weighing <20 kg and 20 ml/aliquot instilled up to a total volume of 3 ml/kg in children weighing >20 kg. Some adjust instilled volume to 10% of the functional residual capacity with 5–20 ml/aliquot depending on the patient's size.[5],[6],[7],[8],[9],[10],[11] The aim of this study was to determine the appropriate location of BAL in infants and children with regard to the volume recovered from different lobes of the lung.


  Materials and Methods Top


Study setting and subject

This study was a prospective, observational study at Queen Sirikit National Institute of Child Health, Bangkok. All children aged 1 month to 15 years who were admitted for BAL between January and December 2017 were enrolled. The study was approved by the Institutional Review Board.

Bronchoalveolar lavage protocol

BAL was performed with the flexible bronchoscope (FB) under general anesthesia in an operating room. The size of FB, diameter of which ranged from 2.8 to 3.6 mm, with a 1.2 mm working channel (Olympus Medical Systems Corp., Tokyo, Japan) varied according to the patient's age and body weight. The type of artificial airway used (e.g., laryngeal mask airway, endotracheal tube, or tracheostomy) depended on the patient's clinical status and the anesthesiologist's opinion. Topical lidocaine was applied into larynx, trachea, and bronchi through the FB before BAL.

The sterile isotonic saline was instilled with a total volume of 2–3 ml/kg, divided into 2–6 aliquots. The instilled volume, the number of the aliquots, and the location of BAL varied depending on the patient's body weight, clinical status, radiological, and endoscopic findings. BAL was performed once in each lobe. In a patient with diffuse infiltration, the instilled volume was 0.5 ml/kg/aliquot for 5–6 times. In patients with localized or patchy infiltration, the instilled volume was 3–10 ml/aliquot for 2–4 times. Removal of fluid was done after each instillation by mechanical wall suction using negative pressures of 100–150 mmHg. The percentage of volume recovered was calculated as the volume recovered × 100/the volume instilled. The amount and percentage of volume recovered from different locations were compared.

Statistical analysis

All descriptive data were expressed as a median and interquartile range (IQR) or number (percentage). Comparison of volume recovered from various locations was calculated using the Mann–Whitney U-test and Kruskal–Wallis test as appropriate. The P < 0.05 was considered statistically significant. Statistical analyses were performed using the SPSS Statistical software version 23 (SPSS: International Business Machines Corp., New York, USA).


  Results Top


A total of 66 consecutive patients underwent BAL during the study period. The median age was 1.6 years (IQR 0.83–5.1). Thirty-nine patients (59%) were male. The most common indication for BAL was recurrent pneumonia (65%), followed by bronchiectasis (9%) [Table 1]. There was no serious complication from FB and BAL in this study, except for a low-grade fever in 10 patients which was resolved spontaneously.
Table 1: Patient characteristics

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Forty-seven patients (71.2%) with diffuse infiltration underwent BAL in 5–6 lobes. The total instilled volume was 19 ml (IQR 15, 24), with an average of 2 ml/kg. The total volume recovered was 4.3 ml (IQR 2.78, 6.22) or 20.67% (IQR 13.45, 31.78) of the instilled volume [Table 2].
Table 2: Bronchoalveolar lavage data

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The volume recovered from the right lung was significantly higher than the volume recovered from the left lung (23% vs. 18.89%, P = 0.019). The volume recovered from the RML, the usual recommended location was 23.3% (IQR 13.33, 40.0). The volume recovered from the RLL was 25% (IQR 13.1, 33.75). There was no statistically significant difference in the volume recovered from all lobes in either side of the lung [Table 3].
Table 3: Comparison of bronchoalveolar lavage data performed in different location

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All children were allocated to two groups based on body weight: Group A <10 kg, and Group B >10 kg. Among Group A, 31 patients, the percentage of fluid recovered from the RLL was the highest (25%, IQR 12.50, 33.33), followed by the lingula (22.50%, IQR 7.08, 30.00). Among 35 patients in Group B, the highest volume recovered was from the RML (25%, IQR 18.10, 40.0), followed by the RLL (23.33%, IQR 13.33, 36.25). In both groups, the total volume recovered from the right lung was higher than the left lung. However, there was no significant difference in the volume recovered from all lobes in both groups [Table 4].
Table 4: Comparison of bronchoalveolar lavage data in children weighed <10 kg and ≥10 kg

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  Discussion Top


This study demonstrated that the volume recovered from BAL at the right lung (23%, IQR 13.4, 32.58) was higher than BAL at the left lung (18.89%, IQR 12.50, 30.00) (P = 0.019). The volume recovered from BAL at the RLL tended to be higher than BAL at the RML and right upper lobe (RUL) in infant and children (P = 0.275). To the best of our knowledge, the RML or lingula was the preferred location for BAL in patients with diffuse lung diseases.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] In infants, the BAL was easily performed in the RLL.[6] Rosell et al. found that the volume recovered from the anterior part of the lung (anterior segments of RUL, left upper lobe [LUL], lingula, and RML) was greater than the volume recovered from other segments due to effect of gravity.[12] Previous airway studies in children have shown that the right main bronchus was significantly larger than the left main bronchus, and the RLL bronchus was significantly larger than the LLL bronchus.[13],[14] This might explain the greater volume recovered from the right lung and RLL in our study. However, while the higher volume recovered was from the RLL in the patients weighing <10 kg, the RML was associated with higher volume recovered in the patients weighing >10 kg.

There is no standardization for BAL procedure in children. The instilled volume in children is generally 1 ml/kg or maximum of 10–20 ml/aliquot for 3 times.[5],[6],[7],[8],[9] In this study, a single-aliquot BAL from each lobe was performed by normal saline instillation 0.5 ml/kg (or 3–5 ml) up to 5–6 lobes. However, the actual total instilled volume was only 2 ml/kg. The volume recovered in this study was only 20% (IQR 13.45, 31.78) which was technically unacceptable.[3],[5],[6],[8] Nevertheless, this was not our primary concern. BAL in infant and young children tends to be associated with low volume recovery due to the small and collapsible bronchus which closed easily during suction.[7] The majority of our patients were infants with a median age of 1.6 years. Our prior observation, using instilled volume >1 ml/kg or 10 ml/aliquot for 2–3 times had negligible impact on the volume recovered.

Most BAL procedures (86%) were performed in 4–6 lobes. The BAL sample from one or two lobes was insufficient in evaluation of the lower airway infection in children with cystic fibrosis because of the interlobar differences in BAL microbiological findings.[15],[16] In patient with suspected aspiration, it may be optimal to perform BAL in the dependent lung segments.[2] In the current study, the RLL and the RML provided higher volume recovered than the others.


  Conclusions Top


The current study suggests that BAL performed at the right lung is associated with the greatest fluid recovery. BAL sampling at the RLL and RML were recommended for infants and children with diffuse lung disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Riedler J, Grigg J, Robertson CF. Role of bronchoalveolar lavage in children with lung disease. Eur Respir J 1995;8:1725-30.  Back to cited text no. 1
    
2.
Faro A, Wood RE, Schechter MS, Leong AB, Wittkugel E, Abode K, et al. Official American Thoracic Society technical standards: Flexible airway endoscopy in children. Am J Respir Crit Care Med 2015;191:1066-80.  Back to cited text no. 2
    
3.
Meyer KC, Raghu G, Baughman RP, Brown KK, Costabel U, du Bois RM, 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;185:1004-14.  Back to cited text no. 3
    
4.
American Thoracic Society. Clinical Education: Bronchoalveolar Lavage. Available from: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/critical-care-procedures/bronchoalveolar-lavage.php. [Last accessesd on Apr 2018 01].  Back to cited text no. 4
    
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Midulla F, Nenna R. Bronchoalveolar lavage: Indications and applications. In: Priftis KN, Anthracopoulos MB, Eber E, Koumbourlis AC, Wood RE, editors. Paediatric Bronchoscopy. Vol. 38. Basel: Karger; 2010. p. 30-41.  Back to cited text no. 5
    
6.
de Blic J, Midulla F, Barbato A, Clement A, Dab I, Eber E, et al. Bronchoalveolar lavage in children. ERS task force on bronchoalveolar lavage in children. European Respiratory Society. Eur Respir J 2000;15:217-31.  Back to cited text no. 6
    
7.
Eber E. Bronchoalveolar lavage in pediatric patients. J Bronchology 1998;5:227-41.  Back to cited text no. 7
    
8.
Radhakrishnan D, Yamashita C, Gillio-Meina C, Fraser DD. Translational research in pediatrics III: Bronchoalveolar lavage. Pediatrics 2014;134:135-54.  Back to cited text no. 8
    
9.
Ratjen F, Bruch J. Adjustment of bronchoalveolar lavage volume to body weight in children. Pediatr Pulmonol 1996;21:184-8.  Back to cited text no. 9
    
10.
Gidaris D, Kanakoudi-Tsakakoudi F, Papakosta D, Tzimouli V, Taparkou A, Ventouri M, et al. Bronchoalveolar lavage in children with inflammatory and noninflammatory lung disease. Hioopkrata 2010;14:109-14.  Back to cited text no. 10
    
11.
Nicolai T. The role of rigid and flexible bronchoscopy in children. Paediatr Respir Rev 2011;12:190-5.  Back to cited text no. 11
    
12.
Rosell A, Xaubet A, Agustí C, Castella J, Puzo C, Curull V, et al. A new BAL fluid instillation and aspiration technique: A multicenter randomized study. Respir Med 2006;100:529-35.  Back to cited text no. 12
    
13.
Tan GM, Tan-Kendrick AP. Bronchial diameters in children – Use of the Fogarty catheter for lung isolation in children. Anaesth Intensive Care 2002;30:615-8.  Back to cited text no. 13
    
14.
Masters IB, Ware RS, Zimmerman PV, Lovell B, Wootton R, Francis PV, et al. Airway sizes and proportions in children quantified by a video-bronchoscopic technique. BMC Pulm Med 2006;6:5.  Back to cited text no. 14
    
15.
Gilchrist FJ, Salamat S, Clayton S, Peach J, Alexander J, Lenney W. Bronchoalveolar lavage in children with cystic fibrosis: How many lobes should be sampled? Arch Dis Child 2011;96:215-7.  Back to cited text no. 15
    
16.
Gutierrez JP, Grimwood K, Armstrong DS, Carlin JB, Carzino R, Olinsky A, et al. Interlobar differences in bronchoalveolar lavage fluid from children with cystic fibrosis. Eur Respir J 2001;17:281-6.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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