Performance of a standardized bronchoalveolar lavage protocol in a comprehensive cancer center: a prospective 2-year study

Abstract

Background: Flexible bronchoscopy with bronchoalveolar lavage (BAL) is performed widely for the diagnosis of pulmonary infections in patients with cancer, but there is no consensus regarding the technical parameters of the lavage procedure in this setting.

Methods: The authors evaluated the mechanics (instilled and recovered volumes), diagnostic yield, and safety of a standardized BAL protocol in 284 patients with cancer who underwent bronchoscopy for the evaluation of new radiologic infiltrates.

Results: Physician adherence to the BAL protocol was > 90%. The most common protocol deviations were reductions in the saline volume instilled because of actual or anticipated oxyhemoglobin desaturation during the procedure. The mean volume instilled was 121.5 ± 13.9 mL, the mean volume recovered was 68.7 ± 18.1 mL, and the mean ratio of volume instilled to that recovered was 56.7% ± 14.5%. The overall diagnostic yield of BAL was 33.8% and was higher in the nonhematologic malignancy group (42.3% vs 29.4%; P = .021). The diagnostic yield in neutropenic patients was significantly higher than in non-neutropenic patients (41.5% vs 24.6%; P = .019). No major complications were encountered.

Conclusions: In summary, the diagnostic performance of a standardized BAL protocol was comparable to that of nonprotocolized BAL reported in the literature with few complications. Adherence to a standardized BAL protocol may improve clinical and laboratory comparisons between studies, potentially facilitating research into the diagnosis and management of pneumonia in patients with cancer.

Figure 1

These charts illustrate the mechanical performance of a standardized bronchoalveolar lavage (BAL) protocol. The mechanical parameters of a standardized BAL protocol were assessed based on the clinical records of 274 procedures with complete details. Extracted data included (A) the volume of saline instilled for each procedure and (B) the volume of effluent collected. These values were used to calculate (C) the ratio of volume recovered/instilled.

Figure 2

This flow chart illustrates the diagnostic yield of standardized bronchoalveolar lavage (BAL) in a comprehensive cancer center. After allowing for underlying patient malignancy categories (hematologic malignancy [Heme] or other than hematologic malignancy [Non-Heme]), prospectively enrolled BAL procedures were classified as diagnostic if a true pathogen or a malignancy was identified. Nondiagnostic samples were classified further as revealing either no microbial pathogen or revealing a microbe that was not believed likely to cause the presenting syndrome (colonization/contamination).

Figure 3

This flow chart illustrates the diagnostic yield of bronchoscopic washings. Washings were sent for microbiologic and cytologic analysis at the discretion of the physicians who performed standardized bronchoalveolar lavage (BAL) After allowing for underlying patient malignancy categories (hematologic malignancy [Heme] or other than hematologic malignancy [Non-Heme]), prospectively enrolled BAL procedures were classified as diagnostic if a true pathogen or a malignancy was identified. Nondiagnostic samples were classified further as revealing either no microbial pathogen or revealing a microbe that was not believed likely to cause the presenting syndrome (colonization/contamination).