Bronchoscopic performance of bronchoalveolar lavage in Germany – a call for standardization A request for BAL standardization

Main Article Content

Juergen Hetzel
Michael Kreuter
Christian Kähler
Hans-Joachim Kabitz
Andreas Gschwendtner
Ralf Eberhardt
Ulrich Costabel
Kaid Darwiche


Bronchoscopy; bronchoalveolar lavage; interstitial lung disease; BAL survey


Background: Bronchoalveolar lavage (BAL) is a widely used clinical tool in diagnosing interstitial lung diseases. Although there are recommendations and guidelines, the procedure is not completely standardized. Varying approaches likely influence the conclusiveness of BAL data and may be one reason for the divergent judgement of their value between different centers. Objectives: To evaluate how BAL is performed in Germany using an electronically based survey. Methods: We conducted a cross-sectional online survey among all members of the German Respiratory Society. Results: 608 members responded to the survey and of these 500 perform lavages.  Most bronchoscopists (344/500) do not use a tube and have no anesthesiologist present during the procedure (405/500). Propofol is used by 76.8% and midazolam by 67.9% (n = 405), often in combination. A major difference was noted regarding the total volume of instillation. Many respondents use a predefined fixed amount of instilled volume (202/500), whereas an almost equal number use variable volumes based on the recovery (196/500). The minimum recovery volume predefined by 217/499 ranged from 3-150 ml (median 30 ml; mean 42.2 ± 55.1 ml). Most respondents did not transport their samples in special medium (61.5%) or on ice (72.8%). The average time between recovery and arrival at the lab was 115.6±267.0 min (n = 323). Conclusions: This study shows the broad spectrum of variations in the performance of BAL in Germany, which could have a negative effect on the method’s clinical value. There is a need for training and standardization of BAL performance.


Download data is not yet available.
Abstract 508 | PDF Downloads 221


1. Myrvik Q, Leake ES, Fariss B. Studies on pulmonary alveolar macrophages from the normal rabbit: a technique to procure them in a high state of purity. J Immunol. 1961;86:128–32.
2. Toetsch M, Guzman J, Theegarten D, Schmid K., Costabel U. [Bronchoalveolar lavage]. Pathologe. 2007;28:346–53.
3. Keimowitz RI. Immunglobulins in normal human tracheobronchial washings. J Lab Clin Med. 1964;63:54–9.
4. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183:788–824.
5. Raghu G, Remy-Jardin M, Myers JL, et al. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2018;198:e44–68.
6. Meyer KC, Raghu G, Baughman RP, et al. An official American Thoracic Society clinical practice guideline: the clinical utility of bronchoalveolar lavage cellular analysis in interstitial lung disease. Am J Respir Crit Care Med. 2012;185:1004–14.
7. Klech H, Pohl W. Fiberbronchoscopy in Technical recommendations and guidelines for bronchioloalveolar Lavage (BAL). Report of the ERS Task Group. Eur Respir J. 1989;2:561–85.
8. Hautmann H, Eberhardt R, Heine R, et al. Empfehlung zur Sedierung in der flexiblen Bronchoskopie. Pneumologie. 2011;65:647–52.
9. Bonella F, Ohshimo S, Bauer P, Guzman J, Costabel U. Bronchoalveolar lavage. Interv Pulmonol. European Respiratory Society Journals Ltd; 2010. p. 59–72.
10. Duddridge M, Kelly CA, Ward C, Hendrick DJ, Walters EH. The reversible effect of lignocaine on the stimulated metabolic activity of bronchoalveolar lavage cells. Eur Respir J. 1990;3:1166–72.
11. Costabel U, Barth J, Behr J, Buhl R, Kanzow G, Klech H. [Recommendations for diagnostic bronchoalveolar lavages]. Pneumologie. 1993;47:607–19.
12. Pingleton SK, Harrison GF, Stechschulte DJ, Wesselius LJ, Kerby GR, Ruth WE. Effect of location, pH, and temperature of instillate in bronchoalveolar lavage in normal volunteers. Am Rev Respir Dis. 1983;128:1035–7.
13. Costabel U. [Atlas of the Bronchoalveolar Lavage]. Stuttgart: Thieme; 1994.

Most read articles by the same author(s)

1 2 > >>