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Feasibility of the utility of bronchoalveolar lavage, bronchial brushings, and transbronchial needle aspiration in nonneoplastic lung diseases


 Department of Pathology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

Date of Submission30-Oct-2020
Date of Decision14-Dec-2020
Date of Acceptance01-Dec-2020

Correspondence Address:
Pushpanjali R Ojha,
Rajendra Institute of Medical Sciences, Ranchi - 834 009, Jharkhand
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_445_20



How to cite this URL:
Ojha PR. Feasibility of the utility of bronchoalveolar lavage, bronchial brushings, and transbronchial needle aspiration in nonneoplastic lung diseases. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=321297



The history of direct visualized tissue sampling from pulmonary lesions had started with the invention of flexible bronchoscopy (FOB) by S Ikeda in 1967.[1] These advances further with the modern era of medical science and at present sampling adequacy had reached >90% with the help of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and electromagnetic navigational bronchoscopy approaches up to 6th- to 8th-generation airways.[2] Gahlot and Mogra reported that the variety of diagnostic specimen availability has increased with bronchoscopy, and FOB has an excellent result when combined with brushing cytology and biopsy.[3]

What is new in this study? – There are >28,000 research articles about bronchoscopic tissue diagnosis of pulmonary pathologies mostly focused on malignancies, with few describing its role in nonneoplastic lesions. This study had analyzed all the three different types of samples for the diagnosis of nonneoplastic lesions. Bronchoscopy is primarily an area of interest for interventional pulmonologists, hence limited to the centers having pulmonary medicine departments.[2] This limitation would be a cause for the existence of numerous single-center studies with paucity of multicentric analysis of the same.

What kind of samples one can observe in pulmonary pathology? – Sputum sampling is the first step in the diagnosis of nonneoplastic pulmonary lesions followed by radiography, but because it has preanalytic limitations and poor specificity and sensitivity,[4] bronchoscopy-guided tissue sampling will can be used in diagnosing those lesions with increased sensitivity and specificity. Bronchoalveolar lavage (BAL) and bronchial brushing (BB) are the types of exfoliative cytology with increased sensitivity and specificity in diagnosing intraluminal lesions. TBNA is the process of performing direct tissue sampling from the lesion, hence it is more useful in diagnosing deeply seated lesions in the lung parenchyma as well as mediastinal lesions.

what lung pathologies are diagnosed in the present study–Paradis et al. had stated that biopsies of alveolar tissue via FOB are useful in diagnosing many interstitial lung diseases including sarcoidosis, noninterstitial pneumonia, and idiopathic pulmonary fibrosis.[2]

Tuberculosis and interstitial pneumonia were the most common findings in this study which itself are the most prevalent pulmonary pathologies that need physician consultation. The review study of Ye et al. reported a pooled sensitivity and specificity of 80% and 100%, respectively, for EBUS-TBNA-mediated diagnosis of intrathoracic tuberculosis. This is most helpful in the cases of lymphadenopathy with negative microbiologic sputum cultures.[5] Navani et al. in their study concluded that EBUS-TBNA is a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy.[6]

What is interesting in this study? – The rare but interesting findings of this study were of pulmonary alveolar proteinosis and eosinophilic pneumonitis. The type and number of cases presented to any center will depend on various environmental and epidemiological factors such as temperature and humidity of that area, population density, occupations, industrialization, air pollution, health awareness, personal habits including addictions, as well as inherited disorders.

Is statistics utilized are adequate? – The selection of statistical tools for study analysis is well efficient in deriving the results. The diagnostic yield in the form of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) was maximum with TBNA and least with BAL.[4] This could be because of direct sampling from the lesion in TBNA in comparison to exfoliative cytology in the case of BAL. The evaluation of combined sensitivity, specificity, PPV, and NPV for BAL and BB, BAL and TBNA, BB and TBNA, and all the three tests together is a unique finding. This guides clinicians very well in the selection of the test of choice for diagnosis. Sensitivity and PPV increase with the combination of all the three tests along with minimal NPV (40.3%). In situations with limited access, one should opt for combined BB + TBNA as the diagnostic modality of choice with highest sensitivity (65.4%), specificity (90.0%), PPV (95.8%), and NPV 42.1%). This increases the diagnostic accuracy and minimizes the number of bronchoscopic tissue sampling frequency. The major highlight of this study is the derivation of test score that represents the number of tests among BAL, BB, and TBNA that were positive for a particular disease. This increases the validity and utility of this study further in the diagnosis of specific group of diseases. The disease-specific statistical analysis guides a clinician in the selection of method of choice for a specific disease.

Is the study has any limitation? – The study is limited in diagnosing sarcoidosis and fungal infections by any means of the tests except TBLB because of the paucity of the number of cases available. Fungal infections have higher yield with BAL in comparison to that of other methods,[2] which was missed in the present study.

The limitations of the study are single-center design, small sample size, zero test score for fungal infections and sarcoidosis, and failure to include occupational diseases.



 
  References Top

1.
Panchabhai TS, Mehta AC. Historical perspectives of bronchoscopy. Connecting the dots. Ann Am Thorac Soc 2015;12:631-41.  Back to cited text no. 1
    
2.
Paradis TJ, Dixon J, Tieu BH. The role of bronchoscopy in the diagnosis of airway disease. J Thorac Dis 2016;8:3826-37.  Back to cited text no. 2
    
3.
Gahlot A, Mogra N. Role of fiberoptic bronchoscopy in histopathological analysis of lung lesions. IAIM 2016;3:130-5.  Back to cited text no. 3
    
4.
Ojha PR, Madan R, Bharadwaj R. Correlation between sputum and bronchoscopy guided cytology (bronchoalveolar lavage fluid, transbronchial needle aspiration and bronchial brush) with bronchial biopsy in the diagnosis of pulmonary pathology. Arch Med Health Sci 2019;7:25-32.  Back to cited text no. 4
  [Full text]  
5.
Ye W, Zhang R, Xu X, Liu Y, Ying K. Diagnostic efficacy and safety of endobronchial ultrasound-guided transbronchial needle aspiration in intrathoracic tuberculosis: A Meta-analysis. J Ultrasound Med 2015;34:1645-50.  Back to cited text no. 5
    
6.
Navani N, Molyneaux PL, Breen RA, Connell DW, Jepson A, Nankivell M, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: A multicentre study. Thorax 2011;66:889-93.  Back to cited text no. 6
    




 

 
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