Background Information:

What are the other Names for the Procedure?

• BAL (Bronchoalveolar Lavage)

What is Bronchoalveolar Lavage procedure?

• Bronchoalveolar Lavage (BAL) is a diagnostic procedure that allows sampling of sterile fluid from an area of the lung
• A bronchoscope is wedged in a small airway called the sub-segmental bronchus. Sterile normal saline is placed in the bronchial airways and the fluid is then suctioned via the bronchoscope
• The bronchial airways are airway tubes that carry oxygen to the lungs and are a part of the respiratory tract
• The alveoli are the air sacs at the end of the bronchial tubes that allows movement of oxygen across the lung tissue into the pulmonary capillaries

What part of the Body does the Procedure involve?

The procedure involves bronchoscopy evaluation of the trachea (windpipe) and the large and medium sized bronchi (airways). Subsequently, the Bronchoalveolar Lavage is done with instillation of sterile normal saline into the airways through the scope channel.

Why is the Bronchoalveolar Lavage procedure Performed?

There could be various reasons for performing a Bronchoalveolar Lavage from the lungs. Some of these include:

• To evaluate pulmonary infiltrates
• To evaluate recurrent pneumonias
• To evaluate opportunistic pneumonia (caused by fungus, virus, etc.) in lung transplant patients
• To evaluate pulmonary infections such as tuberculosis, fungal infections, pneumocystis in immunosuppressed patients
• To evaluate certain types of lung cancer
• To evaluate pulmonary fibrosis or interstitial lung disease (ILD)
• To evaluate for atypical mycobacterial infection of the lungs
• To evaluate critically ill patients for ventilator-associated pneumonia (VAP)
• To evaluate for rare lung conditions such as eosinophilic pneumonia and alveolar hemorrhage 

What are some Alternative Choices for the Procedure?

Bronchoalveolar Lavage is a unique procedure with no good alternatives.

What are the Recent Advances in the Procedure?

Currently, no significant advances specific to Bronchoalveolar Lavage procedure are reported. 

What is the Cost of performing the Bronchoalveolar Lavage procedure?

The cost of the bronchoscopy procedure with Bronchoalveolar Lavage depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Bronchoalveolar Lavage procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/critical-care-procedures/bronchoalveolar-lavage.php (accessed on 11/11/19)

https://www.ncbi.nlm.nih.gov/books/NBK430762/ (accessed on 11/11/19)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4274523/ (accessed on 11/11/19)

Prior to Bronchoalveolar Lavage procedure:

How is the Bronchoalveolar Lavage procedure Performed?

The bronchoscopy and Bronchoalveolar Lavage are usually outpatient procedures with the patient fasting prior to procedure per physician recommendation.

• The procedure can be done with following anesthesia: Intravenous medications, such as fentanyl and midazolam combination (conscious sedation), monitored anesthesia care (MAC) using propofol, or general anesthesia (with oral airway)
• “Conscious sedation” is the most preferred form of anesthesia for bronchoscopy where only Bronchoalveolar Lavage is being undertaken
• Oxygen is administered for all types of anesthesia. Sometimes, topical anesthesia is sprayed in the oro-pharynx (throat) as well
• The flexible bronchoscope is then passed into the trachea and the airways inspected
• The bronchoscope is wedged into a sub-segmental bronchus. Then, sterile normal saline in instilled through a small working channel in the bronchoscope into the airways
• The fluid is then suctioned through the bronchoscope into the collection cup/trap

Where is the Procedure Performed?

The Bronchoalveolar Lavage procedure is usually performed in a hospital or outpatient endoscopy/surgical procedure suite.

Who Performs the Procedure?

The bronchoscopy procedure with Bronchoalveolar Lavage is usually performed by a pulmonologist. 

How long will the Procedure take?

The bronchoscopy procedure with Bronchoalveolar Lavage usually takes about 10 to 15 minutes, unless other procedures are included, such as transbronchial lung biopsies and/or endobronchial ultrasound (EBUS) evaluation for mediastinal lymph node aspirations.

On considering the pre-procedure examination and post-procedure recovery time, the total time in the procedure suite is about 4 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Medication history and any allergies to medications, latex etc.
• If the patient is under any of the following medications, it has to be promptly informed to the healthcare provider: Aspirin, clopidogrel (Plavix), ticagrelor (Brilinta), warfarin (coumadin), rivaroxaban (Xarelto), apixaban (Eliquis), dabigatran (Pradaxa), enoxaparin (Lovenox) etc. and any other blood thinners that he/she is currently taking
• Any medical or family history of bleeding disorders or blood clots
• Any unusual effects of anesthesia from prior surgery
• History of sleep apnea and CPAP use at home

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to procedure and discuss procedure details with risks for complications and obtain his/her permission (termed informed consent). 

• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• It is strongly advised not to use any cocaine about 7 to 14 days before procedure; and if so, it is important to discuss the same with the physician and anesthesia team
• Smoking should generally be avoided prior to procedure
• Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications taken) with their attending physician well in advance

What is the Consent Process before the Procedure?

The physician will obtain permission for the bronchoscopy with Bronchoalveolar Lavage procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Bronchoalveolar Lavage procedure?

• Blood tests and pregnancy test (if applicable) may be required prior to the procedure
• The patient may have already undergone a chest X-ray or CT scan of the chest, or both
• An EKG may be needed for anesthetic evaluation

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a bronchoscopy?
• What is a Bronchoalveolar Lavage?
• Why is this procedure necessary?  How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Bronchoalveolar Lavage procedure:

What kind of Anesthesia is given, during the Procedure?

• The procedure can be done with following anesthesia: Intravenous medications, such as fentanyl and midazolam combination (conscious sedation), monitored anesthesia care (MAC) using propofol, or general anesthesia (with oral airway)
• “Conscious sedation” is the most preferred form of anesthesia for bronchoscopy where only Bronchoalveolar Lavage is being undertaken, since the procedure time is short
• Oxygen is administered for all types of anesthesia. Sometimes, topical anesthesia is sprayed in the oro-pharynx (throat) as well

How much Blood will you lose, during the Procedure?

Bronchoscopy with Bronchoalveolar Lavage is considered a minimally-invasive procedure, with no risks for bleeding during this procedure.

What are the possible Risks and Complications during the Bronchoalveolar Lavage procedure?

The risks or complications that may arise during bronchoscopy with Bronchoalveolar Lavage include:

• Oxygen desaturations, low blood pressure, and arrhythmias (irregular heart rhythm)
• Anesthesia complications, such as respiratory depression, the need for mechanical ventilation, anaphylactic reactions, etc.

What Post-Operative Care is needed at the Healthcare Facility after the Bronchoalveolar Lavage procedure?

The patient is usually observed by a healthcare professional (a nurse) in the recovery area or PACU (Post-Anesthesia Care Unit) depending on the type of anesthesia that was given during the procedure. Also, the patient vital signs are monitored.

After the Bronchoscopy with Bronchoalveolar Lavage procedure:

What are the possible Risks and Complications after the Bronchoalveolar Lavage procedure?

The risks and complications that may arise after a bronchoscopy with Bronchoalveolar Lavage include:

• Sore throat and cough for up to 6 to 24 hours after the procedure
• Low-grade fevers for 6 to 24 hours after procedure when lavage was done
• Bronchospasm, which is manifested by difficulty in breathing
• Delayed clearance of anesthesia medications leading to prolonged respiratory depression and need for mechanical ventilation
• Uncommonly, low oxygen saturations or cardiac arrhythmias post procedure may result in patient being admitted for observation overnight in the hospital

What is the Prognosis after the Surgery?

• The recovery from the bronchoscopy procedure with Bronchoalveolar Lavage is generally excellent
• The patient is usually discharged after 30 minutes to 1 hour after the procedure. Typically, there may be a follow up with the physician in 2 weeks to review the results

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Shortness of breath more than usual or unexplained difficulty in breathing
• Worsening cough
• Coughing blood
• Unexplained chest pain

What Post-Operative Care is needed at Home after the Bronchoscopy with Bronchoalveolar Lavage procedure?

At home, the following post-operative care is recommended after a bronchoscopy procedure:

• Take simple analgesics, such as acetaminophen (Tylenol) or ibuprofen (Advil), if needed
• Avoid any strenuous activity for a period recommended by the physician
• Do not drive (post-procedure) for a period of 24 hours
• Avoid smoking or drinking alcohol post-procedure
• Continue prescribed medications except for aspirin or blood thinners. It is important to check with the physician on when to resume aspirin or blood thinners
• Do not sign any legal documents post-procedure for a period of 24 hours

How long does it normally take to fully recover, from the Procedure?

Usually, it takes about 12 to 24 hours to completely recover from the effects of the anesthesia and bronchoscopy procedure.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The samples/tissue are usually sent to the microbiology and pathology departments in the hospital, and subsequently disposed, as per the standard hospital protocol.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The samples/tissue is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the bronchoscopy and Bronchoalveolar Lavage procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• The pulmonologist or thoracic surgeon
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before the bronchoscopy and Bronchoalveolar Lavage procedure is performed.