Bronchial Lavage in the Treatment of Severe Bronchopulmonary Pathology in Adults. Approaches to Classification

Introduction Currently, bronchial lavage (BL) is widely used in clinical practice for the treatment of severe bronchopulmonary lesion in adults. However, indications and contraindications for this procedure are not fully defined. In addition, it was not possible to find in the literature a classification of either BL in general or used for therapeutic purposes in particular, which significantly complicates the standardization of procedures for its use in various diseases.

Aim of study To determine possible classification characteristics, as well as indications, contraindications for therapeutic BL in adults and possible complications that may arise, based on the analysis of literature data.

Results Therapeutic BL can be carried out both as planned and for health reasons. Indications for planned BL are purulent bronchitis, pneumonia, purulentdestructive infiltration, as well as chronic lung diseases: bronchiectasis, interstitial lesions. In turn, the indication for emergency therapeutic BL is progressive acute or chronic respiratory failure, developing due to bronchial obstruction. Such conditions may include massive pulmonary hemorrhage, acute obstruction of the bronchi with mucus and pus, postoperative atelectasis and hypoventilation of the lungs, aspiration of gastric contents, severe bronchial asthma, purulent destruction of the lungs, acute respiratory distress syndrome, thermochemical lesions of the respiratory tract. Contraindications to therapeutic BL can be both absolute and relative. Absolute contraindications are intolerance to drugs used for local anesthesia; decompensated heart and (or) pulmonary failure; acute cerebrovascular accident; various types of arrhythmias; stenosis of the larynx and (or) trachea II–III degree; neuropsychiatric diseases; pain syndrome in the abdominal cavity; extremely serious condition of the patient, when clarification of the diagnosis can no longer affect treatment tactics. Relative contraindications include acute respiratory disease of the upper respiratory tract; coronary artery disease; severe diabetes mellitus; pregnancy (second half); chronic alcoholism; grade III enlargement of the thyroid gland. It should be noted that most of the absolute contraindications are conditional and are not taken into account when performing BL according to vital indications with appropriate medical and technical support. Classification of BL used for medicinal purposes can be carried out according to the following criteria: method of sanitation; access used; level of sanitation; sanitized area; volume and composition of the lavage solution. It is noteworthy that the methods of carrying out procedures for various conditions and diseases still remain unregulated. An exception is the final stage of the therapeutic BL procedure in the case of the use of surfactant preparations, which standardization is regulated by approved standard operating procedures. It should also be noted that bronchial lavage for therapeutic purposes is justified from a pathoanatomical and pathophysiological point of view, but is accompanied by serious, albeit temporary, changes in the lungs, which can be partially avoided by improving the lavage technique.

Conclusion All of the above indicates that in order to solve existing problems, it is necessary to conduct systematic research in this direction with the involvement of all interested specialists.

1. Lukomskiy GI, Shulutko ML, Vinner MG, Ovchinnikov AA. Bronkhopul´monologiya. Mosсow: Meditsina Publ.; 1982. (in Russ)

2. Simenstad JO, Galway CF, Maclean LD. Tracheobronchial lavage in treatment of postoperative atelectasis. Minn Med. 1962;45:900–904. PMID: 13913005

3. Simenstad JO, Galway CF, Maclean LD. Tracheobronchial lavage for treatment of aspiration and atelectasis. Surg Forum. 1962;13:155–157. PMID: 13992996

4. Simenstad JO, Galway CF, Maclean LD. The treatment of aspiration and atelectasis by tracheobronchial lavage. Surg Gynecol Obstet. 1962;115:721–728. PMID: 13992995

5. Perry JF Jr, Galway CF. Chest injury due to blunt trauma. J Thorac Cardiovasc Surg. 1965;49:684–693. PMID: 14274352

6. Broom B. Intermittent positive-pressure respiration and therapeutic bronchial lavage in intractable status asthmaticus. Lancet. 1960;1(7130):899–901. PMID: 13804800 https://doi.org/10.1016/S01406736(60)90787-X

7. Finley TN, Swenson EW, Curran WS, Huber GL, Ladman AJ. Bronchopulmonary lavage in normal subjects and patients with obstructive lung disease. Ann Intern Med. 1967;66(4):651–658. PMID: 6023531 https://doi.org/10.7326/0003-4819-66-4-651

8. Ambiavagar M, Jones ES. Resuscitation of the moribund asthmatic. Use of intermittent positive pressure ventilation, bronchial lavage and intravenous infusions. Anaesthesia. 1967;22(3):375–391. PMID: 4952780 https://doi.org/10.1111/j.1365-2044.1967.tb02760.x

9. Rogers RM, Braunstein MS, Shurman JF. Role of bronchopulmonary lavage in the treatment of respiratory failure: a review. Chest. 1972;62(5):Suppl:95S–106. PMID: 4563464 https://doi.org/10.1378/chest.62.5_Supplement.95S

10. Kylstra JA, Rausch DC, Hall KD, Spock A. Volume-controlled lung lavage in the treatment of asthma, bronchiectasis, and mucoviscidosis. Am Rev Respir Dis. 1971;103(5):651–665. PMID: 5579908 https//doi.org/10.1164/arrd.1971.103.5.651

11. Palamarchuk GF, Akopov AL, Arsen’ev AI, Derevyanko AV, Nagornaya OA. Bronkhoskopiya v diagnostike i lechenii zabolevaniy organov dykhaniya. Saint Petersburg: Foliant Publ.; 2019 (in Russ)

12. Thompson HT, Pryor WJ. Bronchial lavage in the treatment of obstructive lung disease. Lancet. 1964;2(7349):8–10. PMID: 14149220 https://doi.org/10.1016/S0140-6736(64)90004-2

13. Thompson HT, Pryor WJ, Hill J. Bronchial lavage in the treatment of obstructive lung disease. Thorax. 1966;21(6):557–559. PMID: 5972524 http://doi.org/10.1136/thx.21.6.557

14. Shteiner ML. Respiratory Protection During Bronchoscopy. Fundamental research. 2012;(1):193–199. (In Russ.)

15. Boyko VV, Krasnoyaryzhsky AG. New Approaches to Pre-Operative Preparation in Struggle Against Post-Operative Complications in Patients With Compression Syndrome Caused by Mediastinum Neoplasms. International Medical Journal. 2009;(4):58–61. (In Russ.)

16. Kassil’ VL, Leskin GS, Vyzhigina MA. Iskusstvennaya i vspomogatel’naya ventilyatsiya legkikh. Moscow: Meditsina Publ.; 2004. (in Russ.)

17. Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasie positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and metaanalysis. BMJ. 2003;326(7382):185. PMID: 12543832 https://doi.org/10.1136/bmj.326.7382.185

18. Mehta S, Nava S. Mask ventilation and cardiogenic pulmonary edema: «another brick in the wall». Intensive Care Med. 2005;31(6):757–759. PMID: 15891861 https://doi.org/10.1007/s00134-005-2650-0

19. Avdeev SN. Vedenie bol’nykh khronicheskoy obstruktivnoy bolezn’yu legkikh s ostroy dykhatel’noy nedostatochnost’yu. Consilium Medicum. 2006;8(3):8–87. (In Russ.)

20. Chhajed PN, Aboyoun C, Malouf MA, Hopkins PM, Plit M, Grunstein RR, et al. Prophylactic nasopharyngeal tube insertion prevents acute hypoxaemia due to upper-airway obstruction during flexible bronchoscopy. Intern Med J. 2003;33(7):317–318. PMID: 12823679 https://doi.org/10.1046/j.1445-5994.2003.00403.x

21. Davidson C, Treacher D. (eds.) Respiratory critical care. London: Arnold; 2002.

22. Shteyner ML, Borodulin BE, Zhestkov AV, Danilin AV. Fibrobronkhoskopiya pri khronicheskikh obstruktivnykh zabolevaniyakh legkikh. Samara: ITIS Publ.; 2003. (In Russ.)

23. McCain TW, Dunagan DP, Adair NE, Chin RJ. Prospective randomized trial comparing oxygen administration during nasal flexible bronchoscopy. Chest. 2001;120(5):1671–1674. PMID: 11713152 https://doi.org/10.1378/chest.120.5.1671

24. Shinagawa N, Yamazaki K, Kinoshita I, Ogura S, Nishimura M. Susceptibility to oxygen desaturation during bronchoscopy in elderly patients with pulmonary fibrosis. Respiration. 2006;73(1):90–94. PMID: 16155353 https://doi.org/10.1159/000088093

25. Steinberg KP, Mitchell DR, Maunder RJ, Milberg JA, Whitcomb ME, Hudson LD. Safety of bronchoalveolar lavage in patients with adult respiratory distress syndrome. Am Rev Respir Dis. 1993;148(3):556–561. PMID: 8368623 https://doi.org/10.1164/ajrccm/148.3.556

26. Hilbert G, Gruson D, Vargas F, Valentino R, Favier JC, Portel L, et al. Bronchoscopy with bronchoalveolar lavage via the laryngeal mask airway in high-risk hypoxemic immunosuppressed patients. Crit Care Med. 2001;29(2):249-255. PMID: 11246301 https://doi.org/10.1097/00003246-200102000-00004

27. Perkins GD, Chatterjee S, Giles S, McAuley DF, Quinton S, Thickett DR, et al. Safety and tolerability of nonbronchoscopic lavage in ARDS. Chest. 2005;127(4):1358–1363. PMID: 15821216 https://doi.org/10.1378/chest.127.4.1358

28. Filippov VP, Chernichenko NV. Bronkhoskopiya pri zabolevaniyakh legkikh. Moscow: BINOM Publ.; 2014. (In Russ.)

29. Technical recommendations and guidelines for bronchoalveolar lavage (BAL). Report of the European Society of Pneumology Task group. Eur Respir J. 1989;2(6):561–585. PMID: 2663535 https://erj.ersjournals.com/content/erj/2/6/561.full.pdf

30. Crystal RG, Reynolds HY, Kalica AR. Brоnchoalveolar lavage. Chest. 1982;90(1):122–131. PMID: 3720374 https://doi.org/10.1378/chest.90.1.122

31. Oho K, Amemiya R. Practical fiberoptic bronchoscopy. 2nd ed. Tokyo: Igaky-Shoin; 1984.

32. Shteyner ML. Dopolnitel’nye diagnosticheskie endobronkhial’nye manipulyatsii: bronkhoal’veolyarnyy lavazh. Zhurnal glavnogo vracha. 2017;24(6):26–38. (In Russ.)

33. Meyer KC. Bronchoalveolar lavage as a diagnostic tool. Semin Respir Crit Care Med. 2007;28(5):546–560. PMID: 17975782 https://doi.org/10.1055/s-2007-991527

34. Chernekhovskaya NE. Sovremennye tekhnologii v endoskopii. Moscow: Rossiyskaya meditsinskaya akademiya poslediplomnogo obrazovaniya Publ.; 2004. (in Russ.)

35. Liu Y, Lu HW, Gu SY, Wang WW, Ge J, Jie ZJ, et al. Bronchoscopic airway clearance therapy for acute exacerbations of bronchiectasis. EBioMedicine. 2021;72:103587. PMID: 34537448 https://doi.org/10.1016/j.ebiom.2021.103587

36. Meyer KC. The role of bronchoalveolar lavage in interstitial lung disease. Chest Med. 2004;25(4):637–649. PMID: 15564013 https://doi.org//10.1016/j.ccm.2004.08.001

37. Mlika М, Ben Kilani М, Berraies А, Braham E, Hamzaoui A, Mezni F. Diagnostic value of the bronchoalveolar lavage in interstitial lung disease. Tunis Med. 2016;94(5):375–384. PMID: 27801489 https://pubmed.ncbi.nlm.nih.gov/27801489/

38. Shang L, Gu X, Du S, Wang Y, Cao B, Wang C. The efficacy and safety of therapeutic lung lavage for exogenous lipoid pneumonia: A systematic review. Clin Respir J. 2021;15(2):134–146. PMID: 32940399 https://doi.org//10.1111/crj.13273

39. Fu W, Xiao Y, Zeng F, Chen X, Zhu Y, Tian Z. et al. Effect of early whole lung lavage at different time-points for promoting the removal of depleted uranium from the lung. Int J Radiat Biol. 2021;97(7):968–976. PMID: 34085887 https://doi.org//10.1080/09553002.2021.1928783

40. Pinchuk TP, Yasnogorodskiy OO, Guryanov JV, Taldykin MV, Kachikin AS, Catane YuA. Diagnostic and curative bronchoscopy for purulentdestructive pulmonary diseases. Pirogov Russian Journal of Surger. 2017;(8):33–39. (In Russ.) https://doi.org/10.17116/hirurgia2017833-39

41. Jiang NN, Wang DY, Xi MM, Luan XG, Jiang MJ, Li F, et al. Retrospective study of fiberoptic bronchoscopy airway lavage in the treatment of extremely severe burn patients with severe inhalation injury. Zhonghua Shao Shang Za Zhi. 2020;36(4):252–259. PMID: 32340414 https://doi.org//10.3760/cma.j.cn501120-20191203-00451

42. Meyer KC, Raghu G, Baughman RP, Brown KK, Costabel U, du Bois RM, 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(9):1004–1014. PMID: 22550210 https://doi.org//10.1164/rccm.201202-0320ST

43. Shi Z, Qin Y, Zhu Y, Pan X, Zhou X, Tan Y, et al. Effect of bronchoalveolar lavage with fiberoptic bronchoscopy combined with vibration sputum drainage on mechanically ventilated patients with severe pneumonia: a prospective randomized controlled trial in 286 patients. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2017;29(1):66–70. PMID: 28459407 https://doi.org//10.3760/cma.j.issn.2095-4352.2017.01.014

44. Patolia S, Farhat R, Subramaniyam R. Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure. J Thorac Dis. 2021;13(8):5125–5134. PMID: 34527353 https://doi.org//10.21037/jtd-19-3709

45. Luisetti M, Meloni F, Ballabio P, Leo G. Role of bronchial and bronchoalveolar lavage in chronic obstructive lung disease. Monaldi Arch Chest Dis. 1993;48(1):54–57. PMID: 8472065 https://pubmed.ncbi. nlm.nih.gov/8472065/

46. Prakash UB. Bronchoscopy. In: Mason RJ, Broaddus VC, Murray JF, Nadel JA. (eds). Murray and Nadel’s textbook respiratory medicine. 4th ed. Philadelphia: Elsevier Saunders; 2005. p. 1617–1650.

47. Patent RU 2286767 C113 Rossiyskaya Federatsiya MPK 51 A61K 31/02 (2006.01); A61B 1/267 (2006/01); A61P 11/00 (2006/01) Al’tshuler E. M., Volzhenin V.V., Krichevskiy A.L., Galeev I.K., Sal’skiy A.V. Sposob lecheniya termoingalyatsionnoy travmy. Zayavka 2005114126/14; Opubl. 2006.11.10. URL: https://yandex.ru/patents/doc/RU2286767C1_20061110 [Data obrashcheniya 24 yanvarya 2024 g.]

48. Uttental’ LO. Vvedenie v dykhatel’nye puti aktivirovannogo belka s pri vospalitel’nykh sostoyaniyakh, porazhayushchikh dykhatel’nye puti. Patent RU 2496515 C213 RF IPC 51 A61K 38/48 (2006.01); Ф61З 11/00 (2006.01). Bull. 2008102656/15; publ. 2013.10.27. (In Russ.) Available at: https://yandex.ru/patents/doc/RU2496515C2_20131027?ysclid=ld9xt1er14637566700 [Accessed Jan 24, 2024]

49. Tarasenko MYu, Shpakov IF, Akulinov EE, Admakin AL, Petrachkov SA, Granov DA, et al. Sposob lecheniya ingalyatsionnykh porazheniy. Patent RU 2238757 C113 RF IPC 51 A61K 38/17 (2006.01); Ф61З 11/00(2006.01). Bull. 2003118700/14; publ. 2004.10.27. (In Russ.) Available at: https://yandex.ru/patents/doc/RU2238757C1_20041027 [Accessed Jan 24, 2024]

50. Provotorov VM, Semenkova GG, Shaydarova VA. Sposob lecheniya khronicheskogo gnoynogo endobronkhita. Patent RU 2070045 C113 RF IPC 51 A61K 33/14. Bull. 93002840/14; publ. 10.12.1996. (In Russ.) Available at: https://patents.google.com/patent/RU2070045C1/ru [Accessed Jan 24, 2024]

51. Agadzhanyan VV, Li GA, Odintsova OV, Kravtsov SA, Fayst EK. Sposob bronkhoal’veolyarnogo lavazha. Patent RU 2160124 C213 RF IPC 51 A61М 1/00 (2006.01); А61К 33/00 (2006.01). Bull. 98113691/14; publ. 2000.12.10. (In Russ.) Available at: https://yandex.ru/patents/doc/RU2160124C2_20001210 [Accessed Jan 24, 2024]

52. Cindrick LL, Gore DC, Herndon DN, Traber LD, Traber DL. Bronchoscopic lavage with perfluorocarbon decreases post procedure hypoxemia in an ovine model of smoke inhalation. J Trauma. 1999;46(1):129–135. PMID: 9932695 https://doi.org/10.1097/00005373-199901000-00022

53. Southern KW, Funkhouser WK, Kazachkova I, Godfey VL, Fordham LA, Gatzy JT, et al. Airway surface liquid recovered by lavage with perfluorocarbon liquid in cats. Eur J Clin Invest. 2002;32(12):956–961. PMID: 12534457 https://doi.org/10.1046/j.1365-2362.2002.01100.x

54. Danilin AV, Shteyner ML, Zhestkov AV, Kibardin AYu. Sposob provedeniya bronkhoal’veolyarnogo lavazha patsientam s massivnoy obstruktsiey bronkhial’nym sekretom. Patent RU 2160124 C213 RF IPC 51 A61М 1/00 (2006/01); A61K 33/00 (2006/01). Bull. 98113691/14, publ. 2000.12.10. (in Russ.) Available at: https://yandex.ru/patents/doc/RU2160124C2_20001210 [Accessed Jan 24, 2024]

55. Chernekhovskaya NE, Andreev VG, Povalyaev AV. Lechebnaya bronkhoskopiya v kompleksnoy terapii zabolevaniy organov dykhaniya. Moscow: MEDpress-inform Publ.; 2008. (In Russ.)

56. Clinical guidelines and indications for bronchoalveolar lavage: Report of the European Society of Pneumology Task Group on BAL. Eup Respir J. 1990;3(8):937–974. PMID: 2292291 https://erj.ersjournals.com/content/erj/3/8/937.full.pdf

57. Strunin L, Abrams ME, Simpson BR. Effects of bronchial lavage on pulmonary surfactant. Proc R Soc Med. 1968;61(11 Pt 1):1162. PMID: 5722563 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1902868/

58. Finley TN, Swenson EW, Curran WS, Huber GL, Ladman AJ. Bronchopulmonary lavage in normal subjects and patients with obstructive lung disease. Ann Intern Med. 1967;66(4):651–658. PMID: 6023531 https://doi.org/10.7326/0003-4819-66-4-651

59. Houmes RJ, Verbrugge SJ, Hendrik ER, Lachmann B. Hemodynamic effects of partial liquid ventilation with perfluorocarbon in acute lung injury. Intens Care Med. 1995;21(12):966–972. PMID: 8750120 https://doi.org/10.1007/BF01700657

60. Takeda T. Experimental model of respiratory distress syndrome by lung lavage with fluorocarbon. Nihon Sanka Fujinka Gakkai Zasshi. 1989;41(9):1417–1422. PMID: 2584820

61. Kamel T, Helms J, Janssen-Langenstein R, Kouatchet A, Guillon A, Bourenne J, et al. Clinical research in intensive care sepsis group (CRICS-TRIGGERSEP). Benefit-to-risk balance of bronchoalveolar lavage in the critically ill. A prospective, multicenter cohort study. Intens Care Med. 2020;46(3):463–474. PMID: 31912201 https://doi.org/10.1007/s00134-019-05896-4

62. Wang C, Ye S, Wang X, Zhao Y, Ma Q, Wang L. Clinical efficacy and safety of mechanical ventilation combined with fiberoptic bronchoalveolar lavage in patients with severe pulmonary infection. Med Sci Monit. 2019;25:5401–5407. PMID: 31326975 https://doi.org/10.12659/MSM.915507

63. Zhao Y, Dai X, Ji J, Cheng P. Bronchial lavage under fiberoptic bronchoscopy in the treatment of severe pulmonary infection. Pak J Med Sci. 2020;36(3):396–401. PMID: 32292441 https://doi.org/10.12669/pjms.36.3.1539

64. Klein U, Karzai W, Zimmermann P, Hannemann U, Koschel U, Brunner JX, et al. Changes in pulmonary mechanics after fiberoptic bronchoalveolar lavage in mechanically ventilated patients. Intens Care Med. 1998;24(12):289–1293. PMID: 9885882 https://doi.org10.1007/s001340050764

65. Franchineau G, Chommeloux J, Pineton de Chambrun M, Lebreton G, Bréchot N, Hékimian G, et al. Electrical impedance tomography monitoring of bronchoalveolar lavage in patients with acute respiratory distress syndrome. Crit Care Med. 2022;50(3):e231–e240. PMID: 34582417 https://doi.org/10.1097/CCM.0000000000005302