Utilidad del lavado broncoalveolar para la detección microbiológica, y factores asociados, en receptores de trasplante de precursores hematopoyéticos: estudio de cohorte retrospectivo / Usefulness of bronchoalveolar lavage for microbiological detection and asssociated factors in hematopoietic stem cell transplant receivers: a retrospective cohort study

INTRODUCCIÓN: Las opacidades pulmonares en receptores de trasplante de precursores hematopoyéticos (TPH) representan un desafío diagnóstico y son una causa de morbimortalidad. Existen grandes discrepancias con respecto a la sensibilidad diagnóstica del lavado broncoalveolar (LBA), sus complicaciones, y los factores asociados a la identificación microbiológica. OBJETIVO: Conocer la utilidad del estudio microbiológico del LBA en el diagnóstico, modificación de la conducta médica y estimar las complicaciones y mortalidad asociada al procedimiento, en receptores de TPH con opacidades pulmonares. PACIENTES Y MÉTODOS: Estudio de cohorte, retrospectivo, en adultos receptores de TPH a los que se les realizó una broncoscopía con LBA por presentar opacidades pulmonares, en el Hospital Italiano de Buenos Aires entre el 01/01/2011 y el 31/12/2020. RESULTADOS: De los 189 procedimientos analizados, en 79 se logró un hallazgo microbiológico (41,8%) y 122 permitieron modificar la conducta médica (64,6%). En 11 casos se observaron complicaciones graves dentro de las 12 horas (5,8%) de efectuado el LBA. La mortalidad intrahospitalaria fue de 16,8% (N = 21/125). El valor de neutrófilos en sangre previo al LBA (p = 0,037) y la presencia de nódulos pulmonares como lesión tomográfica predominante (p = 0,029) se asociaron independientemente al hallazgo microbiològico global. CONCLUSIONES: Nuestra investigación apoya la realización del LBA como herramienta diagnóstica en pacientes que reciben un TPH y presentan opacidades pulmonares.

BACKGROUND: Lung opacities are a cause of morbimortality in bone marrow transplant patients, and represent a diagnostic challenge. There are large discrepancies regarding the diagnostic sensitivity of bronchoalveolar lavage (BAL), its complications, and the factors associated with microbiological detection. AIM: To know the usefulness of the microbiological study of BAL in the diagnosis, in the modification in medical behavior and to estimate the complications and associated mortality of this diagnostic procedure in patients transplanted with hematopoietic progenitor cells with pulmonary opacities. METHODS: Retrospective cohort study in bone marrow transplant adult patients who underwent bronchoscopy with BAL due to lung opacities at Hospital Italiano de Buenos Aires between 01/01/2011 and 12/31/2020. RESULTS: Of the 189 BAL analyzed, 79 presented a microbiological detection (41.8%) and 122 allowed to modify the medical behavior (64.6%). Severe complications were observed within 12 hours after the procedure in11 cases (5.8%). In-hospital mortality was 16,8% (N = 21/125). The value of blood neutrophils prior to bronchoalveolar lavage (p = 0.037) and the presence of pulmonary nodules as the predominant tomographic lesion (p = 0.029) were independently associated with global microbiological detection. CONCLUSION: Our research supports the performance of BAL as a diagnostic tool in bone marrow transplant patients with lung opacities.

Proteinosis alveolar pulmonar: reporte de caso en paciente con linfoma no hodgkin mesentérico / Pulmonary alveolar proteinosis: report of a case in patient with history of mesenteric non-hodgkin lymphoma

Objetivos: Exponer en base a un caso clínico una revisión de literatura reciente sobre Proteinosis alveolar pulmonar (PAP). Presentación del caso: Revisión de ficha clínica electrónica de paciente de sexo masculino de 76 años con antecedente de linfoma no Hodgkin (LNH) mesentérico, estirpe B de tipo folicular, quien acude en forma reiterada a servicios de urgencia por cuadro de dos meses de evolución de fiebre, compromiso del estado general y tos. Al examen físico destaca crépitos en hemitórax derecho. Se realizó Tomografía computada (TC) de tórax que mostró opacidades pulmonares en vidrio esmerilado periféricas, con engrosamiento septal liso y algunas bandas retráctiles subpleurales. Se manejó ambulatoriamente con Azitromicina por una semana. Sin respuesta, evoluciona con baja de peso y diaforesis nocturna. Nueva TC de tórax en enero 2021, muestra nuevos focos de "empedrado" periféricos extensos, descrito como "crazy paving", focos de vidrio esmerilado difusos extensos, sin condensación y con resolución de bandas retráctiles. Estudio infeccioso negativo. Se realiza lavado broncoalveolar (LBA) con estudio histológico de líquido que muestra proceso inflamatorio crónico con abundantes macrófagos y material proteináceo. Discusión: Tras el descarte de patología infecciosa, se orientó el estudio hacia otras causas de enfermedad parenquimatosa pulmonar. Así, resulta fundamental la descripción correcta del patrón imagenológico tomográfico y el LBA que resultaron compatibles con PAP. Conclusión: La PAP es una patología infrecuente, pero una historia clínica adecuada, el planteamiento de diagnósticos diferenciales de neumonía de lenta resolución, asociado el reconocimiento del patrón radiológico característico y el estudio histológico con LBA permiten realizar un diagnóstico certero, con gran implicancia terapéutica.

Objective: To present a review of recent literature on pulmonary alveolar proteinosis (PAP) based on a clinical case. Presentation of the case: Review of electronic clinical record of a 76 years-old masculine patient with history of mesenteric Non-Hodgkin Lymphoma (NHL) follicular-type lineage B, who repeatedly attended the emergency services due to a two-month history of symptoms of fever, compromised general condition and cough. Physical examination revealed crepitus in the right hemithorax. Chest computed tomography (CT) was performed, which showed peripheral ground-glass pulmonary opacities, with smooth septal thickening and some subpleural retractile bands. He was managed on an outpatient basis with Azithromycin for one week. No response; evolves with weight loss and night diaphoresis. New chest CT in January 2021, shows new extensive peripheral "cobblestone" foci, described as "crazy paving", extensive diffuse ground glass foci, without condensation and with resolution of retractile bands. Negative infectious study. Bronchoalveolar lavage (BAL) was performed with a histological study of the fluid showing a chronic inflammatory process with abundant macrophages and proteinaceous material. Discussion: After ruling out infectious pathology, the study was oriented towards other causes of pulmonary parenchymal disease. Thus, the correct description of the tomographic imaging pattern and the BAL that were compatible with PAP are essential. Conclusion: PAP is an infrequent pathology, but an adequate clinical history, the approach to differential diagnoses of slowly resolving pneumonia, associated with the recognition of the characteristic radiological pattern and the histological study with BAL allow an accurate diagnosis to be made, with great therapeutic implications.

[Therapeutic bilateral lung lavage in an adolescent with pulmonary alveolar proteinosis. Case report]. / Lavado pulmonar bilateral terapéutico en una adolescente con proteinosis alveolar pulmonar. A propósito de un caso.

Pulmonary alveolar proteinosis is an unusual diffuse lung disease characterized by abnormal accumulation of pulmonary surfactant and lipoproteins in the alveolar space, which impairs gas exchange with a variable clinical course, ranging from an asymptomatic clinical presentation to severely affected respiratory failure. A 16-year-old girl with diagnosis of pulmonary alveolar proteinosis presented to our hospital for therapeutic lung lavage after a recent history of progressive dyspnea, respiratory distress, declining lung function measurements, and worsening radiographic abnormalities. We obtained baseline pulmonary function tests and laboratory measurements before and after therapeutic bilateral lung lavage.

La proteinosis alveolar pulmonar es una enfermedad pulmonar difusa caracterizada por la acumulación anormal de surfactante y lipoproteínas en el espacio alveolar, lo cual empeora el intercambio gaseoso y lleva a un curso variable desde una presentación clínica asintomática hasta una falla respiratoria grave. Se presenta a una adolescente de 16 años con este diagnóstico que fue remitida a nuestro Hospital para la realización de un lavado pulmonar total luego de una historia de disnea progresiva, dificultad respiratoria, caída de la función pulmonar y anormalidades radiológicas. Se le realizaron estudios de función pulmonar y mediciones de laboratorio antes y después del lavado pulmonar terapéutico. Luego, la paciente presentó una inmediata mejoría tanto de los síntomas, radiografía de tórax y mediciones de estudios de función pulmonar como en el intercambio gaseoso. El lavado pulmonar total continúa siendo el estándar de oro para el tratamiento de la proteinosis alveolar pulmonar en casos graves.

Bilateral single sesion whole lung lavage under venous-venous ECMO in a case of severe pulmonary alveolar proteinosis: five years follow up. / [Lavado pulmonar total bilateral en una sola sesión bajo ECMO veno-venoso en un caso proteinosis alveolar severa: cinco años de seguimiento.]

Introduction: Pulmonary alveolar proteinosis (PAP) is a rare disease caused by accumulation of proteinaceous material in the alveolar spaces. The most common mechanism implied is the development of antibodies directed to granulocyte macrophage colony stimulating factor (GM-CSF). which inhibits activation of alveolar macrophage, thereby causing accumulation of surfactant. Standard treatment is considered to be whole lung lavage (WLL). Object: We present the case of a 47 years old woman referred for lung transplantation because of combined lung fibrosis and emphysema. Diagnose was change to respiratory failure secondary to PAP. We performed a single cession bilateral WLL under venous-venous ECMO. After a 5 years follow up, the patients remains asymptomatic and with normal pulmonary physiology. Conclusions: The case highlights the importance of careful examination of previous diagnoses, in particular of cases referred for lung transplantation and provides factibility of performing single session bilateral WLL without causing right heart failure.

Introducción: la proteinosis alveolar es una enfermedad rara caracterizada por la acumulación de material proteináceo en los espacios alveolares. El principal mecanismo implicado es el desarrollo de anticuerpos contra el factor estimulante de colonias de granulocitos y macrófagos (GM-CSF), que impide la activación del macrófago alveolar y genera acumulación de surfactante. Su tratamiento estándar es el lavado pulmonar total (LPT). Objetivo: presentar el caso de una mujer de 47 años derivada para trasplante pulmonar por sospecha de combinación de fibrosis y enfisema. Se realizó el diagnóstico insuficiencia respiratoria por proteinosis alveolar pulmonar severa y se realizó tratamiento con lavado pulmonar total bilateral, secuencial y en una sola sesión bajo ECMO veno-venoso. A 5 años del tratamiento, la paciente se encuentra asintomática y con fisiología pulmonar normal. Conclusiones: el caso resalta la importancia de evaluar cuidadosamente el diagnóstico de todos los pacientes, en especial los que son derivados a trasplante pulmonar y muestra la factibilidad de realizar el lavado pulmonar total bajo ECMO veno-venoso sin producir claudicación del ventrículo derecho.

Patrón crazy paving en una mujer joven: hallazgo inesperado y tratamiento no tradicional en un caso de proteinosis alveolar pulmonar / Crazy paving computed tomography pattern in a young woman: unexpected findings and non-traditional treatment in a pulmonary alveolar proteinosis case

El patrón llamado 'crazy paving' en tomografia computada de tórax (TAC) puede deberse a diferentes condiciones siendo una de ellas la Proteinosis Alveolar Pulmonar (PAP), rara condición que puede llevar a insuficiencia respiratoria y a menudo, a la muerte. Presentamos el caso de una mujer joven con una historia de un año de evolución de disnea progresiva y tos seca que consultó por un cuadro de aparición brusca de fiebre, calofríos, malestar general y falla respiratoria hipoxémica severa (PaO2 = 51,9 mmHg con FiO2 = 0,50) en la cual la TAC de tórax mostraba un patrón de empedrado o 'crazy paving' que significó un desafío diagnóstico resuelto finalmente con una biopsia pulmonar quirúrgica que mostró una PAP. Ante el fracaso del tratamiento tradicional de Lavado Pulmonar Total (LPT) se usó una aproximación terapéutica novedosa consistente en una serie de 4 lavados lobares con un perfluorocarbono, Perflubron (PFC) bajo anestesia local seguido por 5 sesiones de Plasmaféresis. Casi inmediatamente después de este tratamiento la paciente evidenció mejoría radiológica y funcional. La PaO2 fue de 89,9 mmHg respirando aire ambiental y la CVF y el VEF1 aumentaron alcanzado respectivamente el 77 y el 75% de sus valores normales de referencia. Dadas las características químicas y físicas del PFC, pensamos que es una alternativa válida al LPT en estos casos.

Crazy paving computed tomography pattern may be due to a number of causes, one of them being Pulmonary Alveolar Proteinosis, a rare condition leading to respiratory failure and often to death. We present the case of a young woman with a one-year history of progressive dyspnea and dry cough, who consulted for an acute onset of fever, chills, malaise and severe hypoxemic respiratory failure (PaO2 = 51.9 mmHg; FiO2 = 0.50) with a 'crazy paving' pattern on chest CT. This diagnostic challenge was resolved by a surgical lung biopsy that showed a pulmonary alveolar proteinosis. Taking into account that the traditional treatment using whole lung lavage had already failed in this patient, a novel therapeutic approach was settled. A series of 4 lobar lavages with a perfluorocarbon (Perflubron) under local anesthesia followed by 5 plasmapheresis sessions were carried out. The patient showed radiographic and functional improvement almost immediately after this treatment. PaO2 was 89.9 mmHg breathing room air and FVC and FEV1 increased to reach 77 and 75% respectively of their normal reference values. Because of its chemical and physical properties we think this novel therapeutic approach should be a valuable alternative to saline solution for whole lung lavage in these cases.

Characterization and outcomes of pulmonary alveolar proteinosis in Brazil: a case series.

OBJECTIVE: Pulmonary alveolar proteinosis (PAP) is a rare disease, characterized by the alveolar accumulation of surfactant, which is composed of proteins and lipids. PAP is caused by a deficit of macrophage activity, for which the main treatment is whole-lung lavage (WLL). We report the experience at a referral center for PAP in Brazil. METHODS: This was a retrospective study involving patients with PAP followed between 2002 and 2016. We analyzed information regarding clinical history, diagnostic methods, treatments, and outcomes, as well as data on lung function, survival, and complications. RESULTS: We evaluated 12 patients (8 of whom were women). The mean age was 41 ± 15 years. Most of the patients were diagnosed by means of BAL and transbronchial biopsy. The mean number of WLLs performed per patient was 2.8 ± 2.5. One third of the patients never underwent WLL. Four patients (33.3%) had associated infections (cryptococcosis, in 2; nocardiosis, in 1; and tuberculosis, in 1), and 2 (16.6%) died: 1 due to lepidic adenocarcinoma and 1 due to complications during anesthesia prior to WLL. When we compared baseline data with those obtained at the end of the follow-up period, there were no significant differences in the functional data, although there was a trend toward an increase in SpO2. The median follow-up period was 45 months (range, 1-184 months). The 5-year survival rate was 82%. CONCLUSIONS: To our knowledge, this is the largest case series of patients with PAP ever conducted in Brazil. The survival rate was similar to that found at other centers. For symptomatic, hypoxemic patients, the treatment of choice is still WLL. Precautions should be taken in order to avoid complications, especially opportunistic infections.

Cell Count Analysis from Nonbronchoscopic Bronchoalveolar Lavage in Preterm Infants.

OBJECTIVES: To establish the reference values, diagnostic accuracy, and effect of various factors on cell count in intubated preterm neonates subjected to nonbronchoscopic bronchoalveolar lavage. STUDY DESIGN: This prospective, cross-sectional, blinded study included preterm neonates ventilated for any reason who underwent nonbronchoscopic bronchoalveolar lavage if they had not previously received postnatal antibiotics or steroids. Lavage was performed before surfactant replacement, if any. A gentle ventilation policy was applied. Pneumonia was diagnosed using clinical criteria, without considering cell count. Investigators performing cell counts were blinded to the clinical data. RESULTS: There were 276 neonates enrolled; 36 had congenital or ventilator-associated pneumonia. In the 240 noninfected babies, median neutrophil count increased significantly after the first 2 days of ventilation (day 1, 2 cells per field [IQR, 0.0-9.5 cells per field]; day 2, 2 cells per field [IQR, 0-15 cells per field]; day 3, 20 cells per field [IQR, 2-99 cells per field]; day 4, 15 cells per field [IQR, 2-96 cells per field]; P < .0001). No significant difference was seen over time in infected babies. Multivariate analysis indicated pneumonia (standardized ß = 0.134; P = .033) and the time spent under mechanical ventilation before nonbronchoscopic bronchoalveolar lavage as factors significantly influencing neutrophil count (standardized ß = 0.143; P = .027). Neutrophil count was correlated with the duration of ventilation (rho = 0.28; P <.001). Neutrophil counts were higher in infected (24 cells/field [IQR, 5-78] cells/field) than in noninfected babies (4 cells/field [IQR, 1-24 cells/field]; P <.001) and had an moderate reliability for pneumonia within the first 2 days of ventilation (area under the curve, 0.745; (95% CI, 0.672-0.810; P = .002). CONCLUSIONS: We provide reference values for airway neutrophil counts in ventilated preterm neonates. Bronchoalveolar lavage neutrophils significantly increase after 2 days of ventilation. Neutrophil count has moderate accuracy to diagnose pneumonia, but only within the first 2 days of ventilation.

Characterization and outcomes of pulmonary alveolar proteinosis in Brazil: a case series / Proteinose alveolar pulmonar: caracterização e desfechos em uma série de casos no Brasil

ABSTRACT Objective: Pulmonary alveolar proteinosis (PAP) is a rare disease, characterized by the alveolar accumulation of surfactant, which is composed of proteins and lipids. PAP is caused by a deficit of macrophage activity, for which the main treatment is whole-lung lavage (WLL). We report the experience at a referral center for PAP in Brazil. Methods: This was a retrospective study involving patients with PAP followed between 2002 and 2016. We analyzed information regarding clinical history, diagnostic methods, treatments, and outcomes, as well as data on lung function, survival, and complications. Results: We evaluated 12 patients (8 of whom were women). The mean age was 41 ± 15 years. Most of the patients were diagnosed by means of BAL and transbronchial biopsy. The mean number of WLLs performed per patient was 2.8 ± 2.5. One third of the patients never underwent WLL. Four patients (33.3%) had associated infections (cryptococcosis, in 2; nocardiosis, in 1; and tuberculosis, in 1), and 2 (16.6%) died: 1 due to lepidic adenocarcinoma and 1 due to complications during anesthesia prior to WLL. When we compared baseline data with those obtained at the end of the follow-up period, there were no significant differences in the functional data, although there was a trend toward an increase in SpO2. The median follow-up period was 45 months (range, 1-184 months). The 5-year survival rate was 82%. Conclusions: To our knowledge, this is the largest case series of patients with PAP ever conducted in Brazil. The survival rate was similar to that found at other centers. For symptomatic, hypoxemic patients, the treatment of choice is still WLL. Precautions should be taken in order to avoid complications, especially opportunistic infections.

RESUMO Objetivo: A proteinose alveolar pulmonar (PAP) é uma doença rara, caracterizada pelo acúmulo alveolar de substância surfactante, composta por proteínas e lipídios. É causada por um déficit de atividade macrofágica, cujo principal tratamento é a lavagem pulmonar total (LPT). Relatamos a seguir a experiência de um centro de referência brasileiro em PAP. Métodos: Estudo retrospectivo com a avaliação de pacientes com PAP acompanhados entre 2002 e 2016. Informações sobre história clínica, métodos diagnósticos, tratamentos realizados e desfechos, incluindo dados de função pulmonar, sobrevida e presença de complicações, foram analisados. Resultados: Foram incluídos 12 pacientes (8 mulheres), com média de idade de 41 ± 15 anos. A maioria dos pacientes foi diagnosticada por LBA e biópsia transbrônquica. A média do número de LPT realizadas por paciente foi de 2,8 ± 2,5. Um terço dos pacientes não foi submetido à LPT. Quatro pacientes (33,3%) apresentaram infecções associadas (criptococose, em 2; nocardiose, em 1; e tuberculose, em 1) e houve 2 óbitos (16,6%): 1 por adenocarcinoma lepídico e 1 por complicações na indução anestésica pré-LPT. Não houve diferença significativa entre os dados funcionais; porém houve uma tendência de aumento da SpO2 ao se comparar os dados iniciais aos do final do seguimento. A mediana de seguimento foi de 45 meses (1-184 meses), com taxa de sobrevida em 5 anos de 82%. Conclusões: Pelo que sabemos, esta é a maior série de casos de PAP no Brasil. A taxa de sobrevida foi semelhante à encontrada em outros centros. A LPT ainda é o tratamento de escolha para pacientes sintomáticos e hipoxêmicos. Deve-se atentar para complicações, especialmente infecções oportunistas.

Pulmonary alveolar proteinosis: a case report. / Proteinosis alveolar pulmonar: a propósito de un caso.

INTRODUCTION: Pulmonary alveolar proteinosis is a rare, diffuse interstitial lung disease, characterized by alveolar obstruction due to the accumulation of pulmonary surfactant. CLINICAL PRESENTATION: A 30-year-old male with progressively worsening dyspnea and non-productive cough for one year. He was a sugar cane plantation worker and had prior recurrent respiratory infections. Physical exam revealed cyanosis, and bilateral coarse and fine rales. Chest computed tomography showed diffuse crazy paving pattern. Bronchoscopy with bronchoalveolar lavage yielded a foamy, thick whitish material. Cytology revealed lymphocytes and acellular proteinaceous eosinophilic material. Transbronchial biopsy confirmed the diagnosis of pulmonary alveolar proteinosis. Patient met criteria for whole lung lavage, responding favorably to this therapy. CONCLUSION: Pulmonary alveolar proteinosis is a rare lung disease and important to consider due to the diagnostic and therapeutic challenge it represents.

INTRODUCCIÓN: La proteinosis alveolar pulmonar es una enfermedad intersticial difusa poco frecuente, en la cual se produce obstrucción alveolar, debido al acúmulo de surfactante pulmonar. REPORTE DEL CASO: Varón de 30 años de edad, presentó disnea progresiva y tos seca de un año de evolución. Antecedente personal: estibador de caña de azúcar. Presentó infecciones respiratorias recurrentes. Al examen físico se encontró cianosis, crepitantes difusos bilaterales y subcrepitantes en bases pulmonares. En la tomografía torácica con contraste se encontró un patrón de "empedrado loco". Se realizó videobroncoscopia con lavado broncoalveolar, aspirando material lechoso, espumoso y mucoso. Por citología se encontró linfocitos y material eosinofílico proteináceo acelular. El estudio anatomopatológico de la biopsia transbronquial reveló proteinosis alveolar pulmonar. El paciente reunió los criterios para tratamiento con lavado broncoalveolar total. Luego de este procedimiento, evolucionó favorablemente. CONCLUSIÓN: La proteinosis alveolar pulmonar constituye una enfermedad importante a considerar, por el desafío diagnóstico y terapéutico que representa.

Importancia del cepillado bronquial a ciegas en lesiones tumorales periféricas no visibles endoscópicamente / Importance of blind bronchial brushing in peripheral endoscopically non visible lesions

Introducción: el diagnóstico rápido de las enfermedades neoplásicas pulmonares, primarias o metastásica, tiene una influencia importante sobre el resultado del tratamiento y el pronóstico de este grupo de enfermedades con alta letalidad. En el diagnóstico de estas se usan varias técnicas, entre ellas el cepillado bronquial para estudio citológico con el cual se alcanza un gran rendimiento diagnóstico en las lesiones visibles endoscópicamente y que también es de gran utilidad en los tumores periféricos diagnosticados en un porciento significativo y con el mínimo de complicaciones. Objetivo: evaluar los resultados del cepillado bronquial a ciegas en lesiones pulmonares periféricas de posible etiología tumoral. Métodos: estudio descriptivo, de corte transversal retrospectivo, en pacientes a los que se les realizó cepillado bronquial a ciegas en lesiones pulmonares periféricas sugestivas de ser tumorales en el servicio de neumología del Hospital Hermanos Ameijeiras, en un periodo de 10 años. Se tomaron en cuenta variables como: la localización de la lesión, cepillado útil para diagnóstico, positivo y negativo, tamaño de la lesión y los diagnósticos definitivos. Resultados: se realizó cepillado a ciegas a 517 pacientes, fue útil para diagnóstico en 491 (95 por ciento), en 289 (56 por ciento) se obtuvo resultado positivo. Conclusiones: el cepillado a ciegas en lesiones pulmonares periféricas tumorales es una técnica que mejora considerablemente el rendimiento diagnóstico del carcinoma broncógeno con un número bajo de complicaciones(AU)

Introduction: The rapid diagnosis of pulmonary, primary or metastatic neoplastic diseases has significant influence on the outcome of treatment and the prognosis of this group of high lethal diseases. In their diagnosis, several techniques are used, among them the bronchial brushing for cytological study which achieves great diagnostic performance in endoscopically visible lesions and it is also very useful in the peripheral tumors diagnosed in a significant percentage and with minimum complications. Objective: To evaluate the results of blind bronchial brushing in peripheral lung lesions of possible tumor etiology. Methods: A descriptive, retrospective, cross-sectional study in patients who underwent blind bronchial brushing in peripheral pulmonary lesions suggestive of tumor was conducted in the Pneumology Department at Hermanos Ameijeiras Hospital, over a period of 10 years. The variables taken into account were location of the lesion, brushing useful for diagnosis, positive and negative results, size of the lesion, and the definitive diagnoses. Results: Blind brushing was performed on 517 patients, it was useful for diagnosis in 491 (95 percent), a positive result was obtained in 289 (56 percent). Conclusions: Blind brushing technique in peripheral lung lesions considerably improves the diagnostic performance of bronchogenic carcinoma with low number of complications(AU)

Comparative analyses of thoracic radiographs and bronchoalveolar lavage of dogs and cats with chronic bronchial diseases / Análise comparativa da radiografia torácica e do lavado broncoalveolar em cães e gatos com doença bronquial crônica

There is a high incidence of bronchitis and asthma cases in veterinary medicine. Thoracic radiographs and bronchoalveolar lavage (BAL) are commonly performed for definitive diagnosis in dogs and cats with suspected bronchitis and asthma. It is believed that a combination of diagnostic tools is the best choice to achieve a diagnosis. The aim of this study was to evaluate the efficacy of thoracic radiographs and BAL in the diagnosis of chronic bronchial disease (CBD) in dogs and cats and whether there is any specific radiographic finding that could influence the indication for bronchoalveolar lavage. It was performed a cross-sectional, prospective, observational study including forty client-owned dogs and cats with lower respiratory tract signs and positive radiographic opacities that were evaluated with BAL followed by cytology and culture. The radiographic results compared with BAL culture showed a sensitivity of 38%, specificity of 95% and accuracy of 65% in detecting patients with pneumonia associated with chronic bronchial disease. Thoracic radiographs were effective in diagnosing 65% of the patients, radiographs plus BAL cytology diagnosed 75% of patients and the combination of radiographs, BAL cytology and culture diagnosed 95% of the patients with chronic bronchial disease. In conclusion, the combination of radiographic examination with BAL followed by cytological and microbiological analyses increases diagnostic success in CBD.

Existe uma alta incidência de casos de bronquite e asma em medicina veterinária. Radiografia torácica e lavado broncoalveolar (LBA) são geralmente realizados para o diagnóstico definitivo em cães e gatos com suspeita de bronquite e asma. Acredita-se que uma combinação de ferramentas diagnósticas é a melhor escolha para se obter um diagnóstico. O objetivo deste estudo foi avaliar a eficácia de radiografias torácicas e do LBA no diagnóstico da doença brônquica crônica (DBC) em cães e gatos e tentar determinar se há algum qualquer achado radiográfico específico que possa influenciar a indicação de lavado broncoalveolar. Foi realizado um estudo prospectivo, observacional, incluindo quarenta cães e gatos com sinais clínicos de trato respiratório inferior e aumento de opacidade radiográfica torácica, os quais foram avaliados com LBA seguido de citologia e cultura bacteriana. Os resultados radiográficos em comparação com a cultura bacteriana do LBA mostraram uma sensibilidade de 38%, especificidade de 95% e acurácia de 65% na detecção de pacientes com pneumonia associada à doença brônquica crônica. As radiografias torácicas foram eficazes em diagnosticar 65% dos pacientes, radiografia mais LBA seguido de citologia diagnosticaram 75% dos pacientes e a combinação de radiografias, LBA seguido de citologia e cultura bacteriana diagnosticaram 95% dos pacientes com doença brônquica crónica. Em conclusão, a combinação de exame radiográfico torácico e LBA seguido de análise citológica e microbiológica aumenta o sucesso diagnóstico na DBC.

Comparative analyses of thoracic radiographs and bronchoalveolar lavage of dogs and cats with chronic bronchial diseases / Análise comparativa da radiografia torácica e do lavado broncoalveolar em cães e gatos com doença bronquial crônica

There is a high incidence of bronchitis and asthma cases in veterinary medicine. Thoracic radiographs and bronchoalveolar lavage (BAL) are commonly performed for definitive diagnosis in dogs and cats with suspected bronchitis and asthma. It is believed that a combination of diagnostic tools is the best choice to achieve a diagnosis. The aim of this study was to evaluate the efficacy of thoracic radiographs and BAL in the diagnosis of chronic bronchial disease (CBD) in dogs and cats and whether there is any specific radiographic finding that could influence the indication for bronchoalveolar lavage. It was performed a cross-sectional, prospective, observational study including forty client-owned dogs and cats with lower respiratory tract signs and positive radiographic opacities that were evaluated with BAL followed by cytology and culture. The radiographic results compared with BAL culture showed a sensitivity of 38%, specificity of 95% and accuracy of 65% in detecting patients with pneumonia associated with chronic bronchial disease. Thoracic radiographs were effective in diagnosing 65% of the patients, radiographs plus BAL cytology diagnosed 75% of patients and the combination of radiographs, BAL cytology and culture diagnosed 95% of the patients with chronic bronchial disease. In conclusion, the combination of radiographic examination with BAL followed by cytological and microbiological analyses increases diagnostic success in CBD.(AU)

Existe uma alta incidência de casos de bronquite e asma em medicina veterinária. Radiografia torácica e lavado broncoalveolar (LBA) são geralmente realizados para o diagnóstico definitivo em cães e gatos com suspeita de bronquite e asma. Acredita-se que uma combinação de ferramentas diagnósticas é a melhor escolha para se obter um diagnóstico. O objetivo deste estudo foi avaliar a eficácia de radiografias torácicas e do LBA no diagnóstico da doença brônquica crônica (DBC) em cães e gatos e tentar determinar se há algum qualquer achado radiográfico específico que possa influenciar a indicação de lavado broncoalveolar. Foi realizado um estudo prospectivo, observacional, incluindo quarenta cães e gatos com sinais clínicos de trato respiratório inferior e aumento de opacidade radiográfica torácica, os quais foram avaliados com LBA seguido de citologia e cultura bacteriana. Os resultados radiográficos em comparação com a cultura bacteriana do LBA mostraram uma sensibilidade de 38%, especificidade de 95% e acurácia de 65% na detecção de pacientes com pneumonia associada à doença brônquica crônica. As radiografias torácicas foram eficazes em diagnosticar 65% dos pacientes, radiografia mais LBA seguido de citologia diagnosticaram 75% dos pacientes e a combinação de radiografias, LBA seguido de citologia e cultura bacteriana diagnosticaram 95% dos pacientes com doença brônquica crónica. Em conclusão, a combinação de exame radiográfico torácico e LBA seguido de análise citológica e microbiológica aumenta o sucesso diagnóstico na DBC.(AU)

Protective effect of early prenatal stress on the induction of asthma in adult mice: Sex-specific differences.

Adversities faced during the prenatal period can be related to the onset of diseases in adulthood. However, little is known about the effects on the respiratory system. This study aimed to evaluate the effects of prenatal stress in two different time-points during pregnancy on pulmonary function and on the inflammatory profile of mice exposed to an asthma model. Male and female BALB/c mice were divided into 3 groups: control (CON), prenatal stress from the second week of pregnancy (PNS1) and prenatal stress on the last week of pregnancy (PNS2). Both PNS1 and PNS2 pregnant females were submitted to restraint stress. As adults, fear/anxiety behaviors were assessed, and animals were subjected to an asthma model induced by ovalbumin. Pulmonary function, inflammatory parameters in bronchoalveolar lavage (BAL) and histology were evaluated. There was a significant decrease in the number of entries and time spent in the central quadrant on the open field test for the PNS1 animals. Females (PNS1) showed improved pulmonary function (airway resistance, tissue damping and pulmonary elastance), significant increase in the percentage of neutrophils and lymphocytes and a decrease in eosinophils when compared to controls. There was a significant decrease in inflammatory cytokines in BAL of both males (IL-5 and IL-13) and females (IL-4, IL-5 and IL-13) from PNS1 and PNS2 when compared to the CON group. Prenatal stress starting from the beginning of pregnancy reduces the impact of asthma development in adult female mice, showing an improved pulmonary function and a lower inflammatory response in the lungs.

Site of Bronchoalveolar Lavage Via Flexible Bronchoscopy and Fluid Return in Children.

BACKGROUND: Despite its widespread use as a diagnostic tool, the procedure for bronchoalveolar lavage (BAL) via flexible bronchoscopy is not standardized in children. Our objective was to examine the dissimilarities in fluid return between the different lobes in children undergoing flexible bronchoscopies with BAL. METHODS: We conducted a review of all pediatric flexible bronchoscopies with BAL conducted at a single institution over a 2-year period. Our predictor of interest was the site of the BAL. Our outcome of interest was the percent of fluid return. We used 1-way analysis of variance with subsequent pairwise comparisons for unadjusted analyses and multivariable linear regression for adjusted analyses. RESULTS: We identified 529 procedures that met prespecified criteria. The mean (SD) percent of fluid return was 52.1 (14.4) for the right middle lobe, 50.7 (16.0) for the lingula (LIN), 50.5 (18.6) for the right or left upper lobes other than LIN (R/L-UL), and 42.2 (18.7) for the right or left lower lobes (R/L-LL). The R/L-LL had significantly lower fluid return when compared with each of the other lobes (P<0.05 for all pairwise comparisons); in contrast, there was no significant difference in fluid return between the other lobes. In our main analysis adjusting for potential confounders, performing the BAL in the right middle lobe, LIN, or R/L-UL increased the fluid return by 11.1% [95% confidence interval (CI), 6.2-16.1], 9.5% (95% CI, 3.2-15.8), and 8.7% (95% CI, 0.9-16.5%), respectively, when compared with the R/L-LL. CONCLUSION: Our results suggest that the lower lobes provide the lowest BAL fluid return in children, whereas the other lobes seem to perform similarly.

[Use of inflammatory markers for monitoring paediatric asthma]. / Utilidad de los marcadores inflamatorios en el control del asma pediátrica.

The assessment of asthma control takes into account the symptoms, quality of life, lung function, and inflammatory markers. In the last few years, there has been a large increase in the number of publications related to the study of biomarkers in the management of paediatric asthma. Despite the large variety of inflammatory markers described in research studies, only a small group has shown to be useful in monitoring the disease. Induced sputum eosinophils offer the most solid evidence in assessing asthma control. Exhaled breath condensate and urinary leucotrienes could be useful in the future if there is standardisation in their procedures and interpretation of the results. Nitric oxide, basic eosinophil cationic protein, and bronchial biopsy with bronchoalveolar lavage, only appeared to be useful in a reduced group of patients.

Utilidad de los marcadores inflamatorios en el control del asma pediátrica / Use of inflammatory markers for monitoring paediatric asthma

La evaluación del control del asma considera la medición de la sintomatología, la calidad de vida, la función pulmonar y los marcadores inflamatorios. En los últimos años se han multiplicado las publicaciones relacionadas con el estudio de biomarcadores en el manejo del asma pediátrica. A pesar de la gran variedad de marcadores inflamatorios descritos en estudios de investigación, solo un pequeño grupo ha demostrado ser útil en el control de la enfermedad. Los eosinófilos en esputo inducido tienen la evidencia más sólida en la medición del control de asma. El condensado de aire exhalado y los leucotrienos urinarios podrían tener utilidad en el futuro si se logran estandarizar sus procedimientos e interpretación de resultados. El óxido nítrico, la proteína catiónica básica del eosinófilo y la biopsia bronquial con lavado broncoalveolar parecieran tener utilidad solo en un grupo reducido de pacientes.

The assessment of asthma control takes into account the symptoms, quality of life, lung function, and inflammatory markers. In the last few years, there has been a large increase in the number of publications related to the study of biomarkers in the management of paediatric asthma. Despite the large variety of inflammatory markers described in research studies, only a small group has shown to be useful in monitoring the disease. Induced sputum eosinophils offer the most solid evidence in assessing asthma control. Exhaled breath condensate and urinary leucotrienes could be useful in the future if there is standardisation in their procedures and interpretation of the results. Nitric oxide, basic eosinophil cationic protein, and bronchial biopsy with bronchoalveolar lavage, only appeared to be useful in a reduced group of patients.

Bronchoalveolar lavage (BAL) in tapirs (Tapirus terrestris) with Mycobacterium tuberculosis / Lavado broncoalveolar (LBA) em antas (Tapirus terrestris) com Mycobacterium tuberculosis

This paper describes the in vivo Bronchoalveolar lavage (BAL) technique by endoscopy in tapirs (Tapirus terrestris) with clinical signs of tuberculosis. The technique was performed in two tapirs, male and female, from Curitiba Zoo, Paraná, Brazil. A flexible endoscope and a polyethylene catheter were used after the chemical restraint of the animals. For BAL technique, 60mL of saline 0.9% were infused with a polyethylene catheter, introduced by the endoscope's working channel, and 15mL of BAL were recovered, analyzed and submitted to cytocentrifugation. Slides were stained by Papanicolaou, periodic acid-Schiff (PAS) and Ziehl-Neelsen methods contained high quantity of inflammatory cells on light microscopy (macrophages 27.5%, lymphocytes 0.5%, neutrophis 67% and eosinophis 5%). BAL samples were submitted to culture, bacilloscopy and PCR and were negative for both animals. Based on this study, it was concluded that the bronchoalveolar lavage technique in tapirs is feasible, simple, noninvasive, practical and fast, providing an important clinical information in vivo regarding the functional status of the lower respiratory tract.(AU)

O presente trabalho descreve a técnica de lavado broncoalveolar (LBA) por endoscopia em antas (Tapirus terrestris) in vivo com sinais clínicos de tuberculose. A técnica foi realizada em duas antas, um macho e uma fêmea, provenientes do Zoológico de Curitiba, Paraná, Brasil, utilizando-se endoscópio flexível e sonda de polietileno, após a contenção química desses animais. Para o LBA, 60mL de solução fisiológica 0,9% foram infundidos com auxílio de cateter de polietileno, introduzido pelo canal de trabalho do endoscópio, e, aproximadamente, 15mL de LBA foram recuperados, acondicionados, analisados e submetidos à citocentrifugação. As lâminas foram coradas pelas técnicas de Papanicolau, ácido periódico de Schiff (PAS) e Ziehl- Neelsen, método que contém altas quantidades de células inflamatórias em microscopia (macrófagos 27,5%, linfócitos 0,5%, neutrófilos 67% e eosinófilos 5%). Amostras de LBA foram submetidas a cultura, baciloscopia e PCR e foram negativas em ambos os animais. Concluiu-se, baseado no presente trabalho, que técnica de lavado broncoalveolar é simples, não invasiva, funcional e rápida. Pode fornecer ao clínico importantes informações acerca do estado de funcionamento do aparelho respiratório in vivo.(AU)

Bronchoalveolar lavage (BAL) in tapirs (Tapirus terrestris) with Mycobacterium tuberculosis / Lavado broncoalveolar (LBA) em antas (Tapirus terrestris) com Mycobacterium tuberculosis

This paper describes the in vivo Bronchoalveolar lavage (BAL) technique by endoscopy in tapirs (Tapirus terrestris) with clinical signs of tuberculosis. The technique was performed in two tapirs, male and female, from Curitiba Zoo, Paraná, Brazil. A flexible endoscope and a polyethylene catheter were used after the chemical restraint of the animals. For BAL technique, 60mL of saline 0.9% were infused with a polyethylene catheter, introduced by the endoscope's working channel, and 15mL of BAL were recovered, analyzed and submitted to cytocentrifugation. Slides were stained by Papanicolaou, periodic acid-Schiff (PAS) and Ziehl-Neelsen methods contained high quantity of inflammatory cells on light microscopy (macrophages 27.5%, lymphocytes 0.5%, neutrophis 67% and eosinophis 5%). BAL samples were submitted to culture, bacilloscopy and PCR and were negative for both animals. Based on this study, it was concluded that the bronchoalveolar lavage technique in tapirs is feasible, simple, noninvasive, practical and fast, providing an important clinical information in vivo regarding the functional status of the lower respiratory tract...

O presente trabalho descreve a técnica de lavado broncoalveolar (LBA) por endoscopia em antas (Tapirus terrestris) in vivo com sinais clínicos de tuberculose. A técnica foi realizada em duas antas, um macho e uma fêmea, provenientes do Zoológico de Curitiba, Paraná, Brasil, utilizando-se endoscópio flexível e sonda de polietileno, após a contenção química desses animais. Para o LBA, 60mL de solução fisiológica 0,9% foram infundidos com auxílio de cateter de polietileno, introduzido pelo canal de trabalho do endoscópio, e, aproximadamente, 15mL de LBA foram recuperados, acondicionados, analisados e submetidos à citocentrifugação. As lâminas foram coradas pelas técnicas de Papanicolau, ácido periódico de Schiff (PAS) e Ziehl- Neelsen, método que contém altas quantidades de células inflamatórias em microscopia (macrófagos 27,5%, linfócitos 0,5%, neutrófilos 67% e eosinófilos 5%). Amostras de LBA foram submetidas a cultura, baciloscopia e PCR e foram negativas em ambos os animais. Concluiu-se, baseado no presente trabalho, que técnica de lavado broncoalveolar é simples, não invasiva, funcional e rápida. Pode fornecer ao clínico importantes informações acerca do estado de funcionamento do aparelho respiratório in vivo...

Repeated whole-lung lavage for unremitting pulmonary alveolar proteinosis: a eight-year follow-up of a case.

Pulmonary alveolar proteinosis (PAP) is a rare clinical syndrome that was first described in 1958. To date, whole-lung lavage (WLL) is still the gold-standard therapy for PAP. Herein, we report the case of a male patient who was diagnosed with PAP by open-lung biopsy 8 years prior to presentation at our clinic. The man underwent his first WLL in 2004 and showed marked clinical and radiological improvement after the operation. However, after his original presentation, proteinaceous material continued to accumulate in his lungs. Lavage was performed four additional times, but these attempts failed to arrest the decline in pulmonary function. Each lavage resulted in significant, although transient, clinical improvement.