bronchoalveolar lavage. Bronchoalveolar lavage Bronchial lavage

And a therapeutic medical procedure involving the introduction of a neutral solution into the bronchi and lungs, its subsequent removal, the study of the state of the respiratory tract and the composition of the extracted substrate.

In the simplest cases, it is used to remove excess mucus in the airways and then study their condition. The subject of the study can also be the fluid removed from the patient's lungs.

Technique

BAL is performed under local anesthesia by introducing an endoscope and special solutions through the nasal airways (and less often through the mouth). The patient's spontaneous breathing is not disturbed. The researcher gradually studies the condition of the bronchi and lungs, and then the washings: with microbiological, causative agents of tuberculosis, pneumocystosis can be detected; in biochemical - changes in the content of proteins, lipids, disproportions in the ratio of their fractions, violations of the activity of enzymes and their inhibitors.

Lavage is taken on an empty stomach, at least 21 hours after the last meal.

Diagnostic value

Of greatest importance for the diagnosis of sarcoidosis (mediastinal form with no radiological changes); disseminated tuberculosis; metastatic tumor processes; asbestosis; pneumocystosis, exogenous allergic and idiopathic fibrosing alveolitis; a number of rare diseases. It can be successfully used to clarify the diagnosis and with limited pathological processes in the lungs (for example, malignant tumors, tuberculosis), as well as with

Lat. lavo wash, rinse)

bronchoscopic method for obtaining flushing from the surface of the smallest bronchi (bronchioles) and alveolar structures of the lungs for cytological, microbiological, biochemical and immunological studies. Lb, which is a diagnostic procedure, should be distinguished from bronchial lavage - therapeutic washing of large and small bronchi in various diseases (for example, with purulent bronchitis, alveolar proteinosis, bronchial asthma).

The study of bronchoalveolar lavage using cytological and immunological methods allows you to establish certain changes in cell viability, their functional activity and the relationship between individual cellular elements, which makes it possible to judge the etiology and activity of the pathological process in the lungs. In diseases characterized by the formation of specific cells and bodies (for example, malignant lungs, hemosiderosis, X), the information content of a cytological examination of bronchoalveolar washings can be equated to the information content of a biopsy. Microbiological examination of bronchoalveolar washings can reveal pathogens of tuberculosis, pneumocystosis; in biochemical - depending on the nature of the disease and its activity, changes in the content of proteins, lipids, disproportions in the ratio of their fractions, violations of the activity of enzymes and their inhibitors. Especially informative is the complex application of the listed methods for the study of bronchoalveolar washings.

The highest value of L.b. has for the diagnosis of disseminated processes in the lungs; sarcoidosis (in the mediastinal form of sarcoidosis with no radiological changes and lungs, the study of bronchoalveolar lavage allows in many cases to detect lung tissue); disseminated tuberculosis; metastatic tumor processes; asbestosis; pneumocystosis, exogenous allergic and idiopathic fibrosing alveolitis; rare diseases (histiocytosis X, idiopathic hemosiderosis, alveolar microlithiasis, alveolar proteinosis). L. b. can be successfully used to clarify the diagnosis and with limited pathological processes in the lungs (for example, malignant tumors, tuberculosis), as well as with chronic bronchitis and bronchial asthma.

Since L.b. performed during a bronchoscopy (bronchoscopy) , should be considered for it. The risk of the study should not exceed its need to clarify the diagnosis. Actually L.b. contraindicated with a significant amount of purulent contents in the bronchial tree, determined both clinically and endoscopically.

Bronchoalveolar lavage is performed both with a rigid bronchoscope under general anesthesia and with fibrobronchoscopy under local anesthesia, after a visual examination of the trachea and bronchi. The washing liquid is injected into the selected segmental with its subsequent vacuum aspiration. It is technically more convenient to infuse liquid into III (with the patient lying down) and IV, V and IX segments (with the patient sitting).

When carrying out L.b. using a rigid bronchoscope rice. one ) a metal guide is inserted through it (at an angle of 20 ° or 45 °, depending on the selected segmental bronchus) and through it - radiopaque No. 7 or No. 8, moving it forward by 3-4 cm up to the bronchi of the 5-6th order or, as it were, wedging them. The position of the catheter can be monitored on the x-ray television screen. Through the catheter into the selected segment of the lung with a syringe in portions of 20 ml pour in an isotonic sodium chloride solution with a pH of 7.2-7.4 and a temperature of 38-40 °.

The volume of the lavage fluid depends on the amount of bronchoalveolar lavage required for the intended studies. Apply less than 20 ml washing solution is impractical, because at the same time, adequate flushing from the bronchoalveolar structures is not achieved. As a rule, the total amount of the solution is 100-200 ml. After the introduction of each portion of the solution, vacuum aspiration of the washout is carried out using an electric suction device into a sterile graduated container. With fibrobronchoscopy, the lavage fluid is administered through a fibrobronchoscope installed at the mouth of the selected segmental bronchus, in doses of 50 ml; aspiration is carried out through the biopsy channel of the fibrobronchoscope.

Bronchoalveolar lavage is atraumatic, well tolerated, and no life-threatening complications were noted during its implementation. Approximately 19% of patients after L.b. observed during the day. In rare cases, aspiration develops.

The resulting bronchoalveolar lavage must be quickly delivered to the appropriate laboratories for research. If this is not possible, then the flush can be stored for several hours in a refrigerator at a temperature of -6° to +6°; a wash intended for the study of non-cellular components can be frozen for a long time.

For cytological examination 10 ml bronchoalveolar lavage immediately after its receipt is filtered through 4 layers of sterile gauze or a fine mesh into a centrifuge tube. Then 10 drops of the filtered wash are mixed on a watch glass with 1 drop of Samson's liquid and fill the counting chamber. Counting cellular elements throughout the chamber, set their number to 1 ml flush. The cellular composition of the bronchoalveolar lavage (endopulmonary cytogram) is determined by microscopic examination of the sediment of the lavage fluid obtained by centrifugation, based on counting at least 500 cells using an immersion lens. This takes into account alveolar macrophages, lymphocytes, neutrophils, eosinophils,. The cells of the bronchial epithelium are not counted due to their small number in the washings.

Bronchoalveolar lavage in healthy non-smokers contains, on average, 85-98% of alveolar macrophages, 7-12% of lymphocytes, 1-2% of neutrophils, and less than 1% of eosinophils and basophils; the total number of cells varies from 0.2․10 6 to 15.6․10 6 in 1 ml. In smokers, the total number of cells and the percentage of leukocytes are significantly increased, alveolar macrophages are in an activated (phagocytic) state,

Changes in the endopulmonary cytogram have a certain direction depending on the etiology and activity of the lung disease. It has been established that a moderate increase in the number of lymphocytes (up to 20%) with a simultaneous decrease in the number of alveolar macrophages is possible with primary tuberculosis of the respiratory organs (bronchoadenitis, miliary pulmonary tuberculosis) and acute forms of secondary pulmonary tuberculosis (infiltrative tuberculosis). In patients with chronic forms of pulmonary tuberculosis in the bronchoalveolar lavage, an increase in the number of neutrophils (up to 20-40%) is noted with a reduced or normal content of lymphocytes.

With sarcoidosis of the lungs in bronchoalveolar lavage, a significant increase in the level of lymphocytes (up to 60-80% in the active phase of the disease) is observed with a decrease in the content of alveolar macrophages. In the chronic course and relapse of the disease, the number of neutrophils also increases. In the case of a reverse development of the process against the background of glucocorticosteroid therapy, the content of lymphocytes decreases, while the number of alveolar macrophages is restored. An increase in the number of neutrophils is prognostically unfavorable and indicates the development of pneumofibrosis.

In a cytological study of bronchoalveolar lavage in patients with exogenous allergic alveolitis, an increase in the number of lymphocytes up to 60% or more is established. The most pronounced is observed in the acute phase of the disease and after an inhalation provocative test with an allergen.

For idiopathic fibrosing alveolitis, an increase in the content of neutrophils in the bronchoalveolar lavage (up to 39-44%) is characteristic. In bronchial asthma, the number of eosinophils in the bronchoalveolar lavage reaches 30-80%, which is an objective diagnostic criterion for allergic inflammation of the bronchial mucosa.

In patients with chronic bronchitis, the number of neutrophils in the bronchoalveolar lavage is increased, the content of alveolar macrophages is reduced, the level of lymphocytes and eosinophils remains within the normal range. In the phase of exacerbation of chronic obstructive and non-obstructive bronchitis in the bronchoalveolar lavage, the content of neutrophils increases to an average of 42%, and in the phase of incipient remission, the number of neutrophils decreases. In patients with exacerbation of purulent bronchitis, the number of neutrophils sharply increases (up to 76%). the level of alveolar macrophages decreases (up to 16.8%).

With malignant tumors of the lungs. hemosiderosis, histiocytosis X. asbestosis, xanthomatosis in bronchoalveolar washings during cytological examination, specific for these diseases can be detected: complexes of tumor cells ( rice. 2 ), hemosiderophages ( rice. 3 ), histiocytes, xanthoma cells.

Bacteriological examination of bronchoalveolar washings in patients with pulmonary tuberculosis allows obtaining Mycobacterium tuberculosis in 18-20% of cases. Microscopically in bronchoalveolar washings with Papanicolaou staining and silver impregnation, Pneumocystis carinii, the causative agent of pneumonia in patients with immunodeficiency states, can be determined.

In a biochemical study of bronchoalveolar washings in patients with pulmonary tuberculosis, sarcoidosis of the lungs, exogenous allergic alveolitis, chronic bronchitis, the average activity of proteases (elastase, collagenase) exceeds the norm. inhibitors of proteolysis (α 1 -antitrypsin) is sharply reduced or absent. High elastase accompanies the development of dystrophic processes in the lungs (emphysema and pneumosclerosis). The study of elastase allows you to identify the initial stages of the development of these processes and carry out in a timely manner. In patients with pulmonary tuberculosis and chronic bronchitis, bronchoalveolar washings show a decrease in the content of phospholipids, which form the basis of the surface-active layer of the alveolar lining. In small forms of pulmonary tuberculosis, this can serve as an additional test for the activity of a specific process.

The study of other components of bronchoalveolar washings, including T- and B-lymphocytes, immune complexes, is carried out mainly for scientific purposes.

Bibliography: Avtsyn A.P. and others. Endopulmonal cytogram, Owls. honey., No. 7, p. 8, 1982, bibliogr., Gerasin V.A. and others. Diagnostic bronchoalveolar lavage. Ter. ., No. 5, p. 102, 1981, bibliogr.; Diagnostic bronchoalveolar lavage, ed. And G. Khomenko. M., 1988, bibliography.

staining according to Wright - Romanovsky; ×1200">

Rice. 3. Micropreparation of bronchoalveolar lavage in pulmonary hemosiderosis: arrows indicate hemosiderophages; staining according to Wright - Romanovsky; ×1200.

Rice. 1. Scheme of bronchoalveolar lavage using a rigid bronchoscope: 1 - body of the bronchoscope; 2 - bronchoscope tube inserted into the right main bronchus; 3 - guide; 4 - radiopaque catheter installed at the mouth of the anterior segmental bronchus; 5 - tube for collecting bronchoalveolar lavage, connected by a tube (6) with an electric suction for vacuum aspiration; the arrows show the direction of the flow of the washing liquid.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

Labrocyte

- This is a bronchoscopic method for obtaining flushing from the surface of the smallest bronchi (bronchioles) and alveolar structures of the lungs for cytological, microbiological, biochemical and immunological studies. It is sometimes used for therapeutic purposes to clear the inflamed airways from excess secretory discharge of purulent contents.

In veterinary practice, we use this diagnostic method for cytological analysis of the obtained material, as well as for bacteriological examination. Thus, the diagnosis includes a qualitative / quantitative assessment of the cells that make up the bronchial mucus (for example, eosinophilic or neutrophilic inflammation predominates in a patient). Also, the obtained material is sown on nutrient media in order to determine which pathogen colonizes the surface of the bronchi and the sensitivity of the found microorganism to antibiotics is titrated.

When exactly is the study done?

Very often, animals with a history of chronic coughing attacks (the onset of symptoms was noted more than 1 month ago), intermittent noisy breathing, asthma attacks, and so on are brought to the veterinarian's appointment.

Interestingly, neither a chest x-ray nor a complete blood count or nasal/conjunctival swabs can help differentiate between feline asthma and bronchitis. Changes on a chest x-ray are nonspecific: as a rule, this is the same type of strengthening of the bronchial or broncho-interstitial pattern. As for washings from the surface of the upper respiratory tract, it should be remembered that the microbial landscape at the level of bronchioles and mucous membranes of the nasal passages is very different, and if mycoplasma is found on the surface of the conjunctiva of the eye, we have no right to say that this pathogen causes irreversible changes at the level of the bronchi.

For dogs, the diagnosis of chronic cough can also be made using BAL. Thus, dog cough can be a symptom of very different diseases. For example, infectious and idiopathic bronchitis show the same changes on a chest x-ray, but require completely different treatment. A very valuable method for the selection of therapy in the development of severe, refractory (resistant) pneumonia in puppies and young dogs. After all, a bacteriological study allows you to accurately determine which pathogen is resistant to the standard antibacterial scheme. It is also possible to accurately and quickly select the necessary and specific antibiotic.

In addition, using the method, we can exclude the syndrome of eosinophilic infiltration of the lungs, which develops in young animals and requires aggressive steroid therapy to stop attacks, while steroids prescribed during an active bacterial process can kill the patient.

How the study is done

To collect swabs from the surface of the bronchi, we use the bronchoscopy method. Approximately to the level of the bronchi of the 2nd-3rd order, a bronchoscope is inserted, which allows you to examine the surface of the bronchial tree, as well as to exclude possible foreign objects that have entered the respiratory tract, for example, during active running. Next, with the help of a bronchoscope, we introduce a small volume of sterile solution and very quickly take it back. The resulting material is examined under a microscope and sown on special media.

Method safety

Bronchoalveolar lavage is considered safe, very effective in diagnosis, and often curative. Characterized by the disappearance of cough for a short time after the procedure. Requires minimal anesthesia (sedation). When carrying out specific preparation, it does not have side effects.

Why do this research?

It is very important to understand that chronic prolonged progressive cough often indicates the development of irreversible, severe broncho-pulmonary problems, which, even with well-chosen therapy, may not respond well to treatment. Feline asthma is characterized by a high risk of sudden death. So a timely diagnosis and selected therapy can get rid of problems at an early stage and significantly improve the quality of life of your pet.

Veterinarian
Filimonova D.M.

The therapeutic and diagnostic procedure, during which a neutral solution is injected into the lungs and bronchi, the airways and the composition of the extracted fluid are studied, is called bronchoalveolar lavage (BAL for short).

Therapeutic is a diagnostic technique with which a doctor can obtain a substrate from small bronchi and alveoli. Manipulation is carried out in order to detect interstitial lung diseases (chronic lung tissue diseases or alveolitis).

Historical information

Back at the beginning of the 20th century, during the treatment of pneumonia, doctors decided to conduct an experimental procedure - washing the bronchi to empty them of the inflammatory fluid. In a hospital setting, bronchoscopy was first performed in 1922. After 38 years, bronchial lavage was performed using an endotracheal tube, later doctors began to use tubes with two lumen.

Traditional bronchoalveolar lavage appeared only in the mid-1990s. Experts came to the conclusion that studies help to establish the nature and characteristics of the course of pulmonary diseases.

During the procedure, the doctor washes the bronchoalveolar region with a special solution (most often sodium chloride is used).

Using the technique, it is possible to obtain fluid and cells from deeply localized sections of the lungs. The procedure is prescribed for clinical purposes and fundamental diagnostics.

The essence of the study

The doctor injects an isotonic solution into the bronchial cavity, due to the sufficiently large volume of the solution (from 100 to 300 milliliters), it reaches the alveoli located next to the bronchi. Fluid flushes the bronchi and returns through the tube. The resulting sputum is sent to the laboratory for appropriate analysis.

BAL is prescribed to detect infection, inflammation, pathology, anomalies, benign and malignant tumors. It is also advisable to carry out manipulation to assess the degree of the disease. As a result of the study, the doctor can detect cellular damage and immune responses.

A specialist can inject a drug into the bronchioles, but this procedure is very rarely used in medical practice.

Indications and contraindications for BAL

The study is done in patients in whom diffuse or focal changes in the lungs were found on a chest x-ray. Indications for manipulation:

pneumonia, bronchiolitis;
pulmonitis;
disseminated tuberculosis;
alveolar proteinosis;
collagenosis;
sarcoidosis;
bronchial asthma;
carcinomatous lymphangitis.

Often bronchoalveolar lavage is performed for the treatment of diseases: lipoid pneumonia, alveolar microlithiasis and cystofibrosis. Changes in the bronchi can be infectious, non-infectious, inflammatory and malignant. When sampling lavage fluid, there is a high probability of detecting pathological disorders.

In lung diseases, alveoli, interstitium and small bronchioles almost always suffer, so bronchoalveolar lavage will help to find out their condition and see cell damage. Diagnosis is contraindicated in patients who:

problems with the heart and blood vessels;
respiratory failure;
pulmonary edema;
allergic reactions occur.

If before the procedure a person feels unwell, dizzy, and there is a rapid heartbeat, these and other signs should be reported to the doctor.

Features of bronchoalveolar lavage

The specialist examines the bronchi, after which the bronchoscope is inserted into the subsegmental or segmental bronchus. Flushing of the corresponding segments starts. If the patient has a diffuse disease, then the solution is injected into the reed segments or bronchi of the middle lobe. When washing the lower lobe, it is possible to obtain a larger amount of sputum and its components.

For a classic study, a specialist introduces a bronchoscope to the mouth of the bronchus.

Sodium chloride or another medicinal solution is heated to a temperature of 36-37 ° C. At this time, a catheter tube is inserted, which is connected to a bronchoscope, into the bronchiole. Liquid is inserted through the tube, and sputum and cells are aspirated back into a special container. The resulting lavage fluid should not be stored in a glass container, as the microphages will stick to the glass and the test results will be incorrect.

On average, the doctor injects 30-60 milliliters of the solution 2-3 times. The maximum volume of fluid that is injected should not exceed 300 milliliters. The number of obtained cells reaches 150-200 milliliters.

Bronchial lavage is sent to the laboratory for research, it is centrifuged for 10-15 minutes. After the manipulation, a precipitate remains, from which smears are prepared. The obtained samples are examined under a microscope. In the laboratory, you can differentiate:

eosinophils;
lymphocytes;
neutrophils;
macrophages and other cells.

It is not recommended to take sputum from a destructive focus, since it contains elements of tissue decay, many neutrophils, intracellular components and cellular detritus. In this regard, the study requires a washout located in the segments of the lungs that are adjacent to the destruction. If the resulting fluid contains more than five percent of the epithelium, it makes no sense to diagnose it, since these are cells obtained not from the bronchoalveolar space, but from the bronchial cavity.

BAL is a simple, non-invasive and well-tolerated examination technique. For several decades, only 1 person died during the diagnosis, and that was due to acute edema of the internal organs and septic shock. The specialists found out the cause of the patient's death: due to the rapid release of mediators of the inflammatory process, pulmonary edema worsened, resulting in multiple organ failure.

Possible Complications

Although the procedure is considered safe and painless, complications may occur due to the volume of solution administered and its temperature. During the manipulation, patients occasionally experience a strong cough, and after diagnosis, bodies are observed after 3-4 hours. Complications and side effects according to statistical indicators after bronchoalveolar lavage occur in 3% of patients, after - in 7%, and at the end of an open lung biopsy are observed in 13%.

The effectiveness of diagnostics

To examine the lungs in medicine, many techniques are used, among which the biopsy is considered the most expensive. Lavage is characterized by high efficiency of the obtained results, low risk of adverse reactions and complications.

To make an accurate and unmistakable diagnosis, the doctor must take a sample from the area that is involved in the pathological process.

Quite often, due to infections, inflammation and bleeding, a specialist cannot timely identify the underlying disease. When large volumes of lavage fluid are obtained, their potential value and the likelihood of detecting disorders in the organ increase.

The period of rehabilitation after therapeutic bronchoscopy

After the study, the patient needs more air, so oxygen enters the human body through the endotracheal tube for 10-15 minutes. This manipulation is done in order to open the collapsed alveoli. During this time, the patient should not move and lie quietly. When oxygen stops entering the patient's body, it should be observed for 15-20 minutes.

In the case when the patient was administered anesthesia, after waking up, it is desirable to immediately stop the air supply - the endotracheal tube is removed. If a person does not wake up after additional oxygen supply, this indicates a pneumothorax or bronchospasm. Bronchospasm should be controlled with bronchodilators. Rupture of lung cells or tracheal injury can provoke the development of pneumothorax. After diagnosis, after 2-3 days, doctors recommend taking an x-ray, which will show the presence of fluid in the lungs.

Within a week after the procedure, the patient must adhere to bed rest, not to burden his body. Eight hours of sleep and a balanced diet will help a person feel great and avoid complications.

Bronchoalveolar lavage is a bronchoscopic method for obtaining fluid from the bronchioles and alveoli. The sample taken is sent for further cytological, biochemical, immunological and microbiological analyses. The results obtained allow the doctor to make an accurate diagnosis and begin an effective course of therapy.

The owners of the patent RU 2443393:

The invention relates to medicine, namely pulmonology, intensive care, and can be used in the treatment of patients with massive obstruction of bronchial secretions. For this, bronchoalveolar lavage is performed in 3 stages. At the 1st stage, "dry" aspiration is carried out without the introduction of a lavage medium of tracheobronchial contents from the trachea and 2 main bronchi - right and left. At the 2nd stage, "dry" aspiration is carried out without the introduction of a lavage medium of tracheobronchial contents from the lobar and segmental bronchi. At the 3rd stage, a limited amount of lavage medium is introduced, 10-20 ml per one lobar bronchial basin. The total amount of the introduced lavage medium is 50-100 ml. The method allows to ensure the safety of bronchoalveolar lavage by eliminating the resorptive syndrome due to the use of a minimum amount of lavage medium.

The invention relates to medicine, in particular to pulmonology and phthisiology, and is intended for bronchoalveolar lavage in patients with severe obstruction of the tracheobronchial tree by bronchial secretions.

Bronchoalveolar lavage is a necessary means for the evacuation of pathologically altered viscous bronchial secretions, which is carried out during bronchoscopy. This is a necessary measure for various lung diseases (bronchial asthma, chronic obstructive pulmonary disease, pneumonia), when the mechanisms of natural drainage of the tracheobronchial tree during coughing are ineffective.

Bronchoalveolar lavage usually involves the introduction of a lavage medium into the lumen during bronchoscopy, necessary to dilute the bronchial secretion and reduce its viscosity. In parallel with the introduction of lavage fluid during bronchological aid, continuous aspiration of bronchial secretions occurs, which, being diluted, is much easier to evacuate.

However, due to the physiological features of the functioning of the tracheobronchial tree, it is possible to aspirate the introduced lavage fluid only by 70-75%. Accordingly, the more secret in the bronchial tree (its accumulation can occur under various pathological conditions) or it has worse rheological properties, i.e. increased viscosity, the more lavage medium is usually used. This prevents normal gas exchange, contributes to the preservation of the oxygen debt of the body, despite the active evacuation of the secret, and in some cases its increase is possible.

Another negative point is the increased absorption as a result of bronchoalveolar lavage of the contents of the tracheobronchial tree. The bronchial secret cannot be removed completely, it is only partially evacuated. The remaining secret, mixing with the non-removable part of the lavage medium, becomes less viscous, its rheological properties are significantly improved. As a result, the absorption of secretion in the tracheobronchial tree is enhanced. Together with it, various biologically active substances enter the bloodstream (decay products of pathogens, cells of the desquamated bronchial epithelium, segmented leukocytes that enter the lumen of the tracheobronchial tree for phagocytic function). As a result, a resorptive syndrome develops, which can have varying degrees of severity: from a moderate temperature reaction to severe encephalopathy with loss of consciousness. Moreover, the volume of the medium introduced during lavage is approximately proportional to the severity of the resorptive syndrome.

The classical method of carrying out bronchoalveolar lavage is known, involving the simultaneous administration of 1500-2000 ml of lavage medium to liquefy bronchial secretions, followed by a single aspiration.

The disadvantage of this method is too much lavage medium. This method was used only when performing rigid subanesthetic bronchoscopy against the background of artificial lung ventilation and complete drug depression of consciousness. Currently, the main method of bronchoscopy is bronchoscopy with flexible bronchoscopes (fibrobronchoscopy or digital bronchoscopy) performed under local anesthesia. With this variant of bronchoscopy, the use of such doses of lavage medium is simply incompatible with life.

A known method of carrying out bronchoalveolar lavage, designed specifically for the implementation of bronchoscopy with flexible rather than rigid bronchoscopes. It consists in successive washing of each segmental bronchus with 10-20 ml of lavage medium with simultaneous removal of bronchial contents. Moreover, as a rule, lavage is carried out first in the bronchial basins of one lung, and then the other. Given that the total number of segments is 19 (10 segments in the right lung and 9 in the left), the total amount of lavage medium ranges from 190 to 380 ml.

The disadvantages of this method are the development of a pronounced resorptive syndrome, which can be especially dangerous when performing fibrobronchoscopy in patients with encephalopathy, and a rather significant amount of lavage fluid that is not completely aspirated during bronchoalveolar lavage. This can be dangerous for patients with initial respiratory failure, which, as a result of fiberoptic bronchoscopy with lavage according to the described option, may increase.

The aim of the present invention is to develop such a method of bronchoalveolar lavage, which would have maximum safety in the initial massive obstruction of the tracheobronchial tree with bronchial secretions.

This goal is achieved by the fact that bronchoalveolar lavage in patients with massive bronchial obstruction is carried out in 3 stages: at the 1st stage, "dry" aspiration is carried out without the introduction of a lavage medium of tracheobronchial contents from the trachea and 2 main bronchi - right and left; at the 2nd stage, "dry" aspiration is carried out without the introduction of a lavage medium of tracheobronchial contents from the lobar and segmental bronchi; at the 3rd stage, a limited amount of lavage medium is introduced, 10-20 ml per one lobar bronchial basin (the total amount of lavage medium injected is 50-100 ml).

The proposed method of bronchoalveolar lavage in patients with massive bronchoobstruction is as follows.

Stage 1 begins with the passage of a flexible bronchoscope through the glottis. At the same time, an electric aspirator is switched on, connected by a flexible tube to a bronchoscope. The vacuum circuit is turned on and aspiration of tracheobronchial contents begins, first from the trachea, then from the main bronchi of the right and left lungs. The sequence of removal of bronchial secretions from the main bronchi is variable: they usually start from the main bronchus, where a greater accumulation of secretion is visually determined. If the secret blocks the biopsy channel of the bronchoscope through which aspiration is carried out, then the bronchoscope is removed and the channel is cleaned outside the tracheobronchial tree. The task of the 1st stage is to restore the air flow through the main sections of the lower respiratory tract.

After that, the 2nd stage begins: "dry" aspiration without the introduction of a lavage medium is carried out in the lobar and segmental bronchi, and the lower lobe bronchial basins are first sanitized, since the bronchial secret accumulates there in large quantities due to natural anatomical features. The task of the 2nd stage is the evacuation of the secret from the bronchi of the II and III orders (lobar and segmental). This stage completes the drainage of the proximal lower respiratory tract.

After that, the 3rd stage begins: the bronchoscope is alternately reintroduced into the lobar bronchi (a limited amount of lavage medium is introduced, 10-20 ml per one lobar bronchial pool); at the same time, aspiration of diluted bronchial secretions is carried out. The task of the 3rd stage is the evacuation of bronchial secretions from the distal parts of the lower respiratory tract, starting from the subsegmental bronchi.

CLINICAL EXAMPLES

1. Patient T-va E.M. 62 years old was hospitalized in the intensive care unit of the MMU "City Hospital No. 4 Samara" on an emergency basis with a diagnosis of "Chronic obstructive pulmonary disease of a severe degree, occurring mainly in the bronchitis type. Exacerbation phase. Severe bronchial asthma, steroid-dependent "Respiratory insufficiency III degree. Chronic cor pulmonale in the phase of decompensation". Upon admission, there was an almost complete cessation of natural expectation, shortness of breath (number of respiratory movements - 31"), severe cyanosis, a decrease in oxygen saturation to 86-87%. Given the patient's clinical signs of increasing obstruction of the tracheobronchial tree with bronchial secretions and rapidly increasing respiratory failure, the decision to conduct fibrobronchoscopy according to emergency indications.During fibrobronchoscopy, a massive accumulation of purulent creamy secretion was found already in n/3 of the trachea, the left main bronchus was completely obstructed by a purulent plug, the right main bronchus was partially obturated.During the 1st stage of bronchoalveolar lavage, it was evacuated a secret from the trachea, then from the left main bronchus (initially it was completely obstructed by bronchial secretions), then from the right main bronchus.During the first stage, the bronchoscope had to be removed twice and mechanically restored the patency of the biopsy channel. During the 2nd stage, the lower lobe basin of the right lung and the lower lobe basin of the left lung were sequentially drained; the middle lobe pool of the right lung, the upper lobe pool of the right lung and the upper lobe pool of the left lung. As a result, the secret was almost completely evacuated from the trachea, as well as from the main, intermediate, lobar and segmental bronchi. During the 3rd stage of lavage, lavage medium (isotonic sodium chloride solution) was alternately introduced into the lobar basins with simultaneous aspiration of bronchial contents in the following sequence: 20 ml - into the lower lobe bronchus of the right lung, 15 ml - into the lower lobar bronchus of the left lung, 10 ml - in the middle lobe bronchus of the right lung, 15 ml - in the upper lobe bronchus of the right lung and 20 ml - in the upper lobe bronchus of the left lung. The patient felt a significant reduction in dyspnea already during bronchoscopy. The manifestations of the resorptive syndrome were minimal, limited to a slight rise in temperature to 37.2°C 7 hours after bronchoscopy and did not require special medical correction. Subsequently, the patient underwent a series of rehabilitation bronchoscopies with therapeutic bronchoalveolar lavage according to the described method, which made it possible to stabilize the process and transfer the patient to the general department for further treatment.

2. Patient P-n G.T., 49 years old, was hospitalized in the 1st pulmonology department of the MMU "City Hospital No. 4 of Samara" on an emergency basis with a diagnosis of "Bilateral lower lobe community-acquired pneumonia of severe degree. Chronic obstructive pulmonary disease severe, occurring mainly in the bronchial type. Phase of exacerbation. Respiratory failure of the III degree. Chronic cor pulmonale in the phase of decompensation. Chronic alcoholism. Dyscirculatory encephalopathy". Oxygen saturation at rest and without oxygen supply did not exceed 85-86%; during auscultation, there was a sharp weakening of breathing, single moist rales. The patient was in a soporous state, contact with him was difficult. Given the patient's clinical signs of increasing obstruction of the tracheobronchial tree with bronchial secretions and rapidly increasing respiratory failure, a decision was made to perform fiberoptic bronchoscopy for emergency indications. When conducting fibrobronchoscopy, a massive accumulation of purulent-hemorrhagic secretion was found, obturating n/3 of the trachea, the left and right main bronchi. During the 1st stage of bronchoalveolar lavage, the secret was evacuated from the trachea, then from the right main bronchus (the secret in the right main bronchus was more viscous), then from the left main bronchus. During the first stage, the bronchoscope had to be removed three times and mechanically restored the patency of the biopsy channel. During the 2nd stage, the lower lobe pool of the right lung, the lower lobe pool of the left lung, the middle lobe pool of the right lung, the upper lobe pool of the right lung, and the upper lobe pool of the left lung were sequentially drained. As a result, the secret was almost completely evacuated from the trachea, as well as the main, intermediate, lobar and segmental bronchi. During the 3rd stage of lavage, lavage medium (0.08% sodium hypochlorite) was alternately introduced into the lobar pools with simultaneous aspiration of bronchial contents in the following sequence: 20 ml - into the lower lobe bronchus of the right lung, 20 ml - into the lower lobe bronchus of the left lung , 20 ml - in the middle lobe bronchus of the right lung, 20 ml - in the upper lobe bronchus of the right lung and 20 ml - in the upper lobe bronchus of the left lung. Within 7 hours after fibrobronchoscopy, the phenomena of dyscirculatory encephalopathy regressed: verbal contact with the patient became possible; he freely oriented himself in space, in time, in his own personality. There were practically no manifestations of the resorptive syndrome. Subsequently, the patient underwent a series of rehabilitation bronchoscopies with therapeutic bronchoalveolar lavage according to the described method, which made it possible to stabilize the process, reduce dyspnea, and restore independent expectoration. The patient was transferred for further treatment to the general department.

The use of the proposed method makes it possible to neutralize such well-known negative effects of bronchoalveolar lavage as resorptive syndrome of varying severity and impaired gas exchange due to the impossibility of complete aspiration of the introduced lavage medium.

This variant of bronchoalveolar lavage allows wider use of sanitation fibrobronchoscopy among patients with massive obstruction by bronchial secretions against the background of various pulmonary pathologies.

The invention is possible and expedient to apply in pulmonology departments, departments of thoracic surgery, as well as intensive care units and intensive care units.

SOURCES OF INFORMATION

1. Thompson H.T., Prior W.J. Bronchial lavage in the treatment of obstructive lung disease. // Lancet. - 1964. - Vol.2, No. 7349. - P.8-10.

2. Chernekhovskaya N.E., Andreev V.G., Povalyaev A.V. Therapeutic bronchoscopy in the complex therapy of respiratory diseases. - MEDpress-inform. - 2008. - 128 p.

3. Clinical guidelines and indications for bronchoalveolar lavage: Report of the European Society of Pneumology Task Group on BAL. //Eup. Respir J. - 1990 - Vol.3 - P.374-377.

4. Technical Recommendation and Guidelines for Bronchoalveolar Lavage. // Ibid. - 1989. - Vol.3. - P.561-585.

5. Wiggins J. Bronchoalveolar lavage. Methodology and application. // Pulmonology. - 1991. - No. 3. - P.43-46.

6. Luisetti M., Meloni F., Ballabio P., Leo G. Role of bronchial and bronchoalveolar lavage in chronic obstructive lung disease. // Monaldi Arch. Chest dis. - 1993. - Vol.48. - P.54-57.

7 Prakash U.B. Bronchoscopy. (In: Mason R.J., Broaddus V.C., Murray J.F., Nadel J.A., eds. Murray and Nadel's textbook respiratory medicine). 4th ed. - Philadelphia: Elsevier Saunders. - 2005. - P.1617-1650.

A method for performing bronchoalveolar lavage in patients with massive obstruction by bronchial secretions, characterized in that lavage is performed in 3 stages: at the 1st stage, "dry" aspiration is carried out without the introduction of a lavage medium of tracheobronchial contents from the trachea and 2 main bronchi - right and left; at the 2nd stage, "dry" aspiration is carried out without the introduction of a lavage medium of tracheobronchial contents from the lobar and segmental bronchi; at the 3rd stage, a limited amount of lavage medium is introduced, 10-20 ml per one lobar bronchial basin (the total amount of lavage medium injected is 50-100 ml).

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