Bronchoalveolar Lavage (BAL) in Pediatrics

Topic Name Introduction Procedure Details Indications Step-by-Step Technique Sample Analysis Complications & Safety

Bronchoalveolar Lavage (BAL) in Pediatrics

BAL is a diagnostic procedure that involves washing a segment of the lung with sterile saline to collect cells and substances for analysis. It's performed during bronchoscopy and provides valuable diagnostic information about lower respiratory tract disorders.

Key Points

• Minimally invasive diagnostic tool
• Performed during flexible bronchoscopy
• Helps diagnose infections and inflammatory conditions
• Valuable for both diagnosis and research
• Requires appropriate patient selection

Understanding BAL Procedure

Basic Concepts

• Saline washing of airway segment
• Collection of fluid for analysis
• Usually takes 10-15 minutes
• Can be done under sedation or anesthesia

Equipment Needed

• Flexible bronchoscope
  • Size appropriate for age
  • Working channel for fluid
• Sterile saline (37°C)
• Collection containers
• Suction apparatus
• Monitoring equipment

Patient Preparation

• Fasting guidelines
  • 6 hours for solids
  • 4 hours for breast milk
  • 2 hours for clear liquids
• Pre-procedure assessment
• Informed consent
• Monitoring setup

Common Indications

Infectious Conditions

• Persistent pneumonia
• Immunocompromised patients with lung infection
• Suspected tuberculosis
• Ventilator-associated pneumonia

Non-Infectious Conditions

• Chronic cough evaluation
• Interstitial lung disease
• Alveolar hemorrhage
• Aspiration syndromes
• Suspected malignancy

Research Applications

• Asthma studies
• Cystic fibrosis research
• Immune response studies

Step-by-Step Technique

Before the Procedure

1. Confirm patient preparation
   • Fasting status
   • Consent
   • Lab results
2. Equipment check
   • Bronchoscope function
   • Suction working
   • Warmed saline ready
3. Patient positioning
   • Usually supine
   • Head slightly extended

During the Procedure

1. Sedation/anesthesia administration
2. Bronchoscope insertion
3. Wedge bronchoscope in target segment
4. Instill warmed saline (1ml/kg aliquots)
5. Gentle suction to retrieve fluid
6. Collect samples in appropriate containers

After the Procedure

1. Monitor vital signs
2. Observe for complications
3. Process samples promptly
4. Document procedure details

Sample Analysis & Interpretation

Normal BAL Fluid Components

Cell Type	Normal Range
Macrophages	85-95%
Lymphocytes	5-15%
Neutrophils	<3%
Eosinophils	<1%

Common Tests Performed

• Cell count and differential
• Microbiological studies
  • Bacterial culture
  • Viral studies
  • Fungal analysis
  • AFB staining/culture
• Cytology
• Special studies
  • PCR for specific pathogens
  • Inflammatory markers
  • Lipid-laden macrophages

Diagnostic Patterns

Condition	Typical Findings
Infection	Increased neutrophils, positive cultures
Aspiration	Lipid-laden macrophages
Allergic inflammation	Increased eosinophils

Complications & Safety Measures

Common Complications

• Transient fever (most common)
• Temporary oxygen desaturation
• Bronchospasm
• Bleeding (usually minor)

Prevention Strategies

• Proper patient selection
• Careful technique
• Appropriate volume of saline
• Continuous monitoring
• Pre-warming saline

Safety Monitoring

• Continuous pulse oximetry
• Heart rate monitoring
• Blood pressure checks
• Temperature monitoring
• Respiratory rate observation

Post-Procedure Care

• Recovery monitoring
• Oxygen supplementation if needed
• Temperature checks
• Discharge criteria assessment
• Follow-up instructions

Video Notes

Further Reading

• ERS Guidelines on BAL in Children
• ATS Official Documents on BAL
• Bronchoalveolar Lavage Procedures
• Children's Hospital Protocols for BAL