Interstitial lung disease: the diagnostic role of bronchoscopy

Diagnostic tools in respiratory medicine (Review)

Recent advancements in diagnostic technologies have significantly transformed the landscape of respiratory medicine, aiming for early detection, improved specificity and personalized therapeutic strategies. Innovations in imaging such as multi-slice computed tomography (CT) scanners, high-resolution CT and magnetic resonance imaging (MRI) have revolutionized our ability to visualize and assess the structural and functional aspects of the respiratory system. These techniques are complemented by breakthroughs in molecular biology that have identified specific biomarkers and genetic determinants of respiratory diseases, enabling targeted diagnostic approaches. Additionally, functional tests including spirometry and exercise testing continue to provide valuable insights into pulmonary function and capacity. The integration of artificial intelligence is poised to further refine these diagnostic tools, enhancing their accuracy and efficiency. The present narrative review explores these developments and their impact on the management and outcomes of respiratory conditions, underscoring the ongoing shift towards more precise and less invasive diagnostic modalities in respiratory medicine.

The Role of Bronchoscopy in the Diagnosis of Interstitial Lung Disease: A State-of-the-Art Review

The diagnostic evaluation of interstitial lung diseases (ILDs) remains challenging due to their heterogeneous etiologies and overlapping clinical and radiographic patterns. A confident diagnosis often necessitates histopathological sampling, particularly when high-resolution computed tomography and serologic assessments are inconclusive. While surgical lung biopsy (SLB) has long been considered the diagnostic gold standard, its invasiveness, associated morbidity, and limited feasibility in high-risk patients have driven the pursuit of less invasive alternatives. Here, we review the current applications, diagnostic yield, procedural techniques, and complications of several bronchoscopic modalities. Bronchoalveolar lavage (BAL) aids in characterizing inflammatory profiles and differentiating among conditions such as hypersensitivity pneumonitis, sarcoidosis, and eosinophilic pneumonia. Endobronchial biopsies (EBBs) and endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) are valuable in diagnosing granulomatous diseases with lymphadenopathy. Transbronchial lung biopsy (TBLB) is effective for peribronchial and centrilobular diseases but is limited by small sample size and tissue distortion. Transbronchial lung cryobiopsy (TBC) enables acquisition of larger, well-preserved parenchymal tissue samples from the peripheral lung. Over recent years, studies have demonstrated that TBC, when interpreted within a multidisciplinary discussion (MDD), achieves diagnostic concordance rates with SLB exceeding 75%, and up to 95% in cases where high diagnostic confidence is reached. When performed in experienced centers using standardized protocols, TBC is considered a viable first-line histopathologic tool in the diagnostic evaluation of ILD. Adequate training and standardization of the TBC procedure are needed to ensure low complication rates and a high yield.

Cancer therapy-related interstitial lung disease

ABSTRACT

With the increasing utilization of cancer therapy, the incidence of lung injury associated with these treatments continues to rise. The recognition of pulmonary toxicity related to cancer therapy has become increasingly critical, for which interstitial lung disease (ILD) is a common cause of mortality. Cancer therapy-related ILD (CT-ILD) can result from a variety of treatments including chemotherapy, targeted therapy, immune checkpoint inhibitors, antibody-drug conjugates, and radiotherapy. CT-ILD may progress rapidly and even be life-threatening; therefore, prompt diagnosis and timely treatment are crucial for effective management. This review aims to provide valuable information on the risk factors associated with CT-ILD; elucidate its underlying mechanisms; discuss its clinical features, imaging, and histological manifestations; and emphasize the clinical-related views of its diagnosis. In addition, this review provides an overview of grading, typing, and staging treatment strategies used for the management of CT-ILD.

Interstitial lung disease in rheumatic diseases: an update of the 2018 review

INTRODUCTION

Interstitial lung disease (ILD) is a potential severe complication of various rheumatic diseases, typically connective tissue diseases (CTD), associated with significant morbidity and mortality. ILD may occur during the course of the disease but may also be its first manifestation. Several cell types are involved in ILD's pathogenesis, and if not controlled, pulmonary inflammation may lead to pulmonary fibrosis.

AREAS COVERED

We searched PubMed, Medline, and the Cochrane Library for papers published between 1995 and February 2017 in the first version, and between 2017 and April 2023 using combinations of words. The most frequent systemic rheumatic diseases associated with ILD are systemic sclerosis (SSc), rheumatoid arthritis (RA), and idiopathic inflammatory myositis. Treatment and monitoring guidelines are still lacking, and current treatment strategies have been extrapolated from the literature on SSc and established treatments for non-pulmonary systemic rheumatic manifestations.

EXPERT OPINION

Given the complexity of diagnosis and the paucity of treatment trials, managing CTD patients with ILD is challenging. It requires the skills of multidisciplinary CTD-ILD clinics including at least rheumatologists and lung specialists.

Bronchoscopic Diagnosis of Severe Respiratory Infections

The diagnosis of severe respiratory infections in intensive care remains an area of uncertainty and involves a complex balancing of risks and benefits. Due to the frequent colonisation of the lower respiratory tract in mechanically ventilated patients, there is an ever-present possibility of microbiological samples being contaminated by bystander organisms. This, coupled with the frequency of alveolar infiltrates arising from sterile insults, risks over-treatment and antimicrobial-associated harm. The use of bronchoscopic sampling to obtain protected lower respiratory samples has long been advocated to overcome this problem. The use of bronchoscopy further enables accurate cytological assessment of the alveolar space and direct inspection of the proximal airways for signs of fungal infection or alternative pathologies. With a growing range of molecular techniques, including those based on nucleic acid amplification and even alveolar visualisation and direct bacterial detection, the potential for bronchoscopy is increasing concomitantly. Despite this, there remain concerns regarding the safety of the technique and its benefits versus less invasive sampling techniques. These discussions are reflected in the lack of consensus among international guidelines on the topic. This review will consider the benefits and challenges of diagnostic bronchoscopy in the context of severe respiratory infection.

Application of computed tomography-based radiomics analysis combined with lung cancer serum tumor markers in the identification of lung squamous cell carcinoma and lung adenocarcinoma

OBJECTIVE

To establish a prediction model of lung cancer classification by computed tomography (CT) radiomics with the serum tumor markers (STM) of lung cancer.

MATERIALS AND METHODS

Two-hundred NSCLC patients were enrolled in our study. Clinical data including age, sex, and STM (squamous cell carcinoma [SCC], neuron-specific enolase [NSE], carcinoembryonic antigen [CEA], pro-gastrin-releasing peptide [PRO-GRP], and cytokeratin 19 fragment [cYFRA21-1]) were collected. A radiomics signature was generated from the training set using the least absolute shrinkage and selection operator (LASSO) algorithm. The risk factors were identified using multivariate logistic regression analysis, and a radiomics nomogram based on the radiomics signature and clinical features was constructed. The capability of the nomogram was evaluated using the training set and validated using the validation set. A correction curve and the Hosmer-Lemeshow test were used to evaluate the predictive performance of the radiomics model for the training and test sets.

RESULTS

Twenty-nine of 1234 radiomics parameters were screened as important factors for establishing the radiomics model. The training (area under the curve [AUC] = 0.925; 95% confidence interval [CI]: 0.885-0.966) and validation sets (AUC = 0.921; 95% CI: 0.854-0.989) showed that the CT radiomics signature, combined with STM, accurately predicted lung squamous cell carcinoma and lung adenocarcinoma. Moreover, the logistic regression model showed good performance based on the Hosmer-Lemeshow test in the training (P = 0.954) and test sets (P = 0.340). Good calibration curve consistency also indicated the good performance of the nomogram.

CONCLUSION

The combination of the CT radiomics signature and lung cancer STM performed well for the pathological classification of NSCLC. Compared with the radiomics signature method, the nomogram based on the radiomics signature and clinical factors had better performance for the differential diagnosis of NSCLC.

The Clinical Approach to Interstitial Lung Disease in Childhood: A Narrative Review Article

Interstitial lung disease (ILD) comprises a group of respiratory diseases affecting the interstitium of the lungs, which occur when a lung injury triggers an abnormal healing response, and an inflammatory process leads to altered diffusion and restrictive respiratory dysfunction. The term "interstitial" may be misleading, as other components of the lungs are usually also involved (epithelium, airways, endothelium, and so on). Pediatric conditions (childhood interstitial lung disease, chILD) are different from adult forms, as growing and developing lungs are affected and more diverse and less prevalent diseases are seen in childhood. Diffuse parenchymal lung disease (DPLD) and diffuse lung disease (DLD) can be used interchangeably with ILD. Known etiologies of chILD include chronic infections, bronchopulmonary dysplasia, aspiration, genetic mutations leading to surfactant dysfunction, and hypersensitivity pneumonitis due to drugs or environmental exposures. Many forms are seen in disorders with pulmonary involvement (connective tissue disorders, storage diseases, malignancies, and so on), but several conditions have unknown origins (desquamative pneumonitis, pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia in infancy, and so on). Currently, there is no consensus on pediatric classification; however, age grouping is proposed as some specific forms are more prevalent in infancy (developmental and growth abnormalities, surfactant dysfunction mutations, etc.) and others are usually seen in older cohorts (disorders in normal or immunocompromised hosts, systemic diseases, etc.). Clinical manifestations vary from mild nonspecific symptoms (recurrent respiratory infections, exercise intolerance, failure to thrive, dry cough, etc.) to a severe clinical picture (respiratory distress) and presentation related to the child's age. The diagnostic approach relies on imaging techniques (CT), but further investigations including genetic tests, BAL, and lung biopsy (VATS) are needed in uncertain cases. Pharmacological treatment is mostly empiric and based on anti-inflammatory and immunomodulatory drugs. Lung transplantation for selected cases in a pediatric transplantation center could be an option; however, limited data and evidence are available regarding long-term survival. International collaboration is warranted to understand chILD entities better and improve the outcomes of these patients.

A Review of Endobronchial-Ultrasound-Guided Transbronchial Intranodal Forceps Biopsy and Cryobiopsy

Benign and malignant mediastinal lesions are not infrequently encountered in clinical practice. Mediastinoscopy has long been considered the gold standard in evaluating mediastinal pathology. Since its introduction into clinical practice, endobronchial-ultrasonography-guided transbronchial fine needle aspiration (EBUS-TBNA) has replaced mediastinoscopy as the initial procedure of choice to evaluate mediastinal lesions and to stage lung cancer. Its diagnostic yield in benign mediastinal lesions and less common malignancies, however, has remained limited. This has led different proceduralists to investigate additional procedures to improve the diagnostic yield of EBUS-TBNA. In recent years, different published reports concluded that the addition of EBUS-guided intranodal forceps biopsy (IFB) and transbronchial cryobiopsy (TBCB) to EBUS-TBNA increases the diagnostic yield especially in benign mediastinal lesions and uncommon mediastinal malignancies. The purpose of this review is to describe how EBUS-IFB and EBUS-TBCB are performed, to compare their diagnostic yields, and to discuss their limitations and their potential complications. In addition, the review will conclude with a proposed algorithm on how to incorporate EBUS-IFB and EBUS-TBCB into clinical practice.

Diagnostic Approaches for Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrosing interstitial pneumonia with a very poor prognosis. Accurate diagnosis of IPF is essential for good outcomes but remains a major medical challenge due to variability in clinical presentation and the shortcomings of existing diagnostic tests. Medical history collection is the first and most important step in the IPF diagnosis process; the clinical probability of IPF is high if the suspected patient is 60 years or older, male, and has a history of cigarette smoking. Systemic assessment for connective tissue disease is essential in the initial evaluation of patients with suspected IPF to identify potential causes of interstitial lung disease (ILD). Radiologic examination using high-resolution computed tomography plays a pivotal role in the evaluation of patients with ILD, and prone and expiratory computed tomography images can be considered. If additional tests such as surgical lung biopsy or transbronchial lung cryobiopsy are needed, transbronchial lung cryobiopsy should be considered as an alternative to surgical lung biopsy in medical centers with experience performing this procedure. Diagnosis through multidisciplinary discussion (MDD) is strongly recommended as MDD has become the cornerstone for diagnosis of IPF, and the scope of MDD has expanded to monitoring of disease progression and suggestion of appropriate treatment options.

Clinical Guidance on the Monitoring and Management of Trastuzumab Deruxtecan (T-DXd)-Related Adverse Events: Insights from an Asia-Pacific Multidisciplinary Panel

Trastuzumab deruxtecan (T-DXd)-an antibody-drug conjugate targeting the human epidermal growth factor receptor 2 (HER2)-improved outcomes of patients with HER2-positive and HER2-low metastatic breast cancer. Guidance on monitoring and managing T-DXd-related adverse events (AEs) is an emerging unmet need as translating clinical trial experience into real-world practice may be difficult due to practical and cultural considerations and differences in health care infrastructure. Thus, 13 experts including oncologists, pulmonologists and a radiologist from the Asia-Pacific region gathered to provide recommendations for T-DXd-related AE monitoring and management by using the latest evidence from the DESTINY-Breast trials, our own clinical trial experience and loco-regional health care considerations. While subgroup analysis of Asian (excluding Japanese) versus overall population in the DESTINY-Breast03 uncovered no major differences in the AE profile, we concluded that proactive monitoring and management are essential in maximising the benefits with T-DXd. As interstitial lung disease (ILD)/pneumonitis is a serious AE, patients should undergo regular computed tomography scans, but the frequency may have to account for the median time of ILD/pneumonitis onset and access. Trastuzumab deruxtecan appears to be a highly emetic regimen, and prophylaxis with serotonin receptor antagonists and dexamethasone (with or without neurokinin-1 receptor antagonist) should be considered. Health care professionals should be vigilant for treatable causes of fatigue, and patients should be encouraged to use support groups and practice low-intensity exercises. To increase treatment acceptance, patients should be made aware of alopecia risk prior to starting T-DXd. Detailed monitoring and management recommendations for T-DXd-related AEs are discussed further.

Observational findings of transbronchial lung biopsy in patients with interstitial lung disease: a retrospective study in Aleppo University Hospital

Clinicians face a significant obstacle when attempting to diagnose interstitial lung disease (ILD) patients. However, a thorough clinical examination together with the proper imaging and diagnostic techniques may provide a reliable diagnosis of a particular kind of ILD, and invasive tests such as rigid bronchoscopy or surgical lung biopsy may not be necessary. The aim of this study is to determine the histologic outcomes of an ILD transbronchial lung biopsy (TBLB) carried out at the university hospital in Aleppo.

Methods

This retrospective cohort research was done between 1 January 2020 and 18 April 2022 at the pulmonary department of Aleppo University Hospital, Syria, using patient records. In our study, 174 patients were examined. We included patients over the age of 18 who were referred or admitted to our department at Aleppo University Hospital after being diagnosed with diffuse parenchymal lung disease based on high-resolution computed tomography and clinical symptoms, while excluding other respiratory diseases such as tuberculosis and coronavirus disease 2019.

Results

Patients in the research were 53±7.1 years old on average. Cough and dyspnea were the most common clinical complaints among the patients, which accounted for 79.12 and 78.16%, respectively. A significant fraction of ground-glass opacity was detected on the high-resolution computed tomography, amounting to 102 (58.62%) and 74 (42.53%) for the reticular lesions, respectively. As a complication there were 40 patients with bleeding, of whom 24 had moderate bleeding, and 11 had major bleeding. We also had three patients with pneumothorax. The diagnostic yield of the TBLB in our ILD patients was 66.66%.

Conclusion

An adequate diagnostic accuracy (66.66%) was detected in the TBLB in confirming the diagnosis of ILD; in addition, the bleeding was the most prevalent complication of this procedure. More interventional studies are needed to compare the diagnostic accuracy of this procedure with other invasive and noninvasive diagnostic methodologies of ILD.

Immune cell profiles and patient clustering in complex cases of interstitial lung disease

Interstitial lung disease comprises numerous clinical entities posing significant challenges towards a prompt and accurate diagnosis. Amongst the contributing factors are intricate pathophysiological mechanisms, an overlap between conditions, and interobserver disagreement. We developed a model for patient clustering offering an additional approach to such complex clinical cases. The model is based on surface phenotyping of over 40 markers on immune cells isolated from bronchoalveolar lavage in combination with clinical data. Based on the marker expression pattern we constructed an individual immune cell profile, then merged these to create a global profile encompassing various pathologies. The contribution of each participant to the global profile was assessed through dimensionality reduction tools and the ensuing similarity between samples was calculated. Our model enables two approaches. First, assessing the immune cell population landscape similarity between patients within a diagnostic group allows rapid identification of divergent profiles, which is particularly helpful for cases with uncertain diagnoses. Second, sample clustering is based exclusively on the calculated similarity of the immune cell profiles, thereby removing physician bias and relying on cellular nearest neighbors.

Lung penetration and pneumococcal target binding of antibiotics in lower respiratory tract infection

OBJECTIVES

To achieve the therapeutic effects, antibiotics must penetrate rapidly into infection sites and bind to targets. This study reviewed updated knowledge on the ability of antibiotics to penetrate into the lung, their physicochemical properties influencing the pulmonary penetration and their ability to bind to targets on pneumococci.

METHODS

A search strategy was developed using PubMED, Web of Science, and ChEMBL. Data on serum protein binding, drug concentration, target binding ability, drug transporters, lung penetration, physicochemical properties of antibiotics in low respiratory tract infection (LRTI) were collected.

RESULTS

It was seen that infection site-to-serum concentration ratios of most antibiotics are >1 at different time points except for ceftriaxone, clindamycin and vancomycin. Most agents have proper physicochemical properties that facilitate antibiotic penetration. In antimicrobial-resistant Streptococcus pneumoniae, the binding affinity of antibiotics to targets mostly decreases compared to that in susceptible strains. The data on binding affinity of linezolid, clindamycin and vancomycin were insufficient. The higher drug concentration at the infection sites compared to that in the blood can be associated with inflammation conditions. Little evidence showed the effect of drug transporters on the clinical efficacy of antibiotics against LRTI.

CONCLUSIONS

Data on antibiotic penetration into the lung in LRTI patients and binding affinity of antibiotics for pneumococcal targets are still limited. Further studies are required to clarify the associations of the lung penetration and target binding ability of antibitotics with therapeutic efficacy to help propose the right antibiotics for LRTI.

First evidence of microplastics isolated in European citizens' lower airway

Microplastics (MPs) have been detected in all environmental locations, including the atmosphere. However, few studies have investigated the presence of airborne MPs in the human respiratory system. Our research purpose was to investigate these pollutants in the lower human airways of 44 adult European citizens, using bronchoalveolar lavage fluid (BALF) collection as a minimally invasive method, that enables the detection of these pollutants in living patients. We studied the relationship between the patients' life habits and physiological parameters, based on background information and medical and occupational history, and the concentration of MPs isolated from their respiratory systems. Our results indicate that most MPs were in the form of microfibers (MFs) (97.06%), with an average concentration of 9.18 ± 2.45 items/100 mL BALF, and only 5.88% (0.57 ± 0.27 items/100 mL BALF) were particulate MPs, without a significant relationship with environmental, physiological, or clinical factors. The average size was 1.73 ± 0.15 mm, with the longest dimension (9.96 mm) corresponding to a polyacrylic fiber. Taken together, the results demonstrated the occurrence of MPs in the lower human airway, although more studies are necessary to elucidate the negative effects these pollutants could induce in the human respiratory system and its associated diseases.

Diagnosis of Hypersensitivity Pneumonitis: Review and Summary of American College of Chest Physicians Statement

Assessment of lung biopsies for the diagnosis of hypersensitivity pneumonitis (HP) is one of the most difficult diagnostic problems for surgical pathologists. It is a form of interstitial lung disease resulting from an immune reaction provoked by an inhaled antigen in susceptible individuals. Although this definition sounds simple, in practice, the diagnosis of HP can be challenging. To address these issues, the American College of Chest Physicians (CHEST) has recently published a guideline for the diagnosis of HP. In this review, we will explore the multidisciplinary diagnostic evaluation of HP with a focus on the pathologic features as outlined in the CHEST guidelines. The histologic criteria are divided into 4 diagnostic categories: (1) Typical nonfibrotic HP or fibrotic HP; (2) Compatible with nonfibrotic HP or fibrotic HP; (3) Indeterminate for nonfibrotic or fibrotic HP; and (4) Alternative Diagnosis. It is important to emphasize that patterns 1 to 3 do not represent discrete histologic entities or pathologic diagnoses. Rather, these categories are meant to serve as a practical guide for organizing a complex set of overlapping histologic patterns into an integrated diagnostic framework for facilitating multidisciplinary discussion. High-resolution computed tomography features are also summarized, emphasizing how the correlation of lung biopsies with computed tomography findings can help to favor the diagnosis, particularly in cases where biopsies are not typical for HP. This review highlights details of the histologic spectrum of HP as well as the utility of different types of biopsies and bronchoalveolar lavage. We also emphasize the importance of multidisciplinary discussion and the complex differential diagnosis.

Age as a Risk Factor in the Occurrence of Complications during or after Bronchoscopic Lung Biopsy

Introduction: Bronchoscopic lung biopsy (BLB) is a widely used procedure. As the world’s population is ageing, more BLBs are performed for older people with comorbidities. The aim of the study was to investigate if an older age is a risk factor for BLB related complications. Materials and Methods: A prospective study at the Centre of Pulmonology and Allergology of Vilnius University Hospital Santaros klinikos was conducted. Seven hundred and eighty-six patients (male 60.6%), mean age 57 ± 16, who underwent BLB, were included. The complications that occurred due to BLB were evaluated. Bleeding and pneumothorax were classified into I° or II° grades depending on their severity. Potential determinants, which may increase the risk of complications, emphasizing on age, were analyzed. Results: Fifty-seven (7.2%) BLB-related complications occurred. There were 27 (3.4%) pneumothoraxes, and 19 (70%) of them required thoracic drainage. Thirty (3.8%) bleeding complications occurred, and four (16%) of them were severe. Higher rates of bleeding were found in the age group ≥65 years, p = 0.001. The risk of bleeding in older patients was 3.2 times higher (95% CI 1.51–6.87). Conclusions: Older age is related to a higher incidence of mild bleeding during BLB. However, the risk of life-threatening complications is low despite the age, and older age should not be considered as a contraindication for the procedure if needed.

Prolonged Inhalation Exposure to Coal Dust on Irradiated Rats and Consequences

The purposes of this study were to research immune system changes and liver and lung tissues in irradiated rats after prolonged exposure to coal dust. A study was carried out on 30 male Wistar rats that were divided into 3 groups: group I, intact animals; group II, exposure to coal dust and 0.2 Gy γ-irradiation; and group III, combined exposure to 6 Gy γ-irradiation and coal dust. The combination of a low and sublethal dose of γ-irradiation with coal dust leads to a significant change in immunity at the remote period. Particularly, the increase in radioactivity at the combined effect causes weakening of phagocytosis, and reduction in T lymphocytes by a factor of 2, immunoglobulin imbalance, and cytokine dysfunction develop secondary immune failure. During prolonged inhalation with coal dust of irradiated animals with the dose of 0.2 Gy, fibrosis and perivascular sclerosis of the bronchial wall of the lungs are formed, and perivascular fibrosis is formed in the liver. The increase in exposure dose up to 6 Gy in combination with coal, in the distant period, caused pulmonary hypertension amid hypertrophy of light arterial vessels and fibrous changes in arteriole, and destructive changes and collection necrosis develop in liver parenchyma. In the case of dust radiation synergy, the increase in doses leads to a significant immune deficiency, which occurs according to the “dose effect” principle; increases damage to animal tissues; and leads to liver tissue necrosis, pulmonary fibrosis, and pulmonary hypertension.

Myositis-associated interstitial lung disease: a comprehensive approach to diagnosis and management

Interstitial lung disease (ILD) frequently complicates the inflammatory myopathies and at times is the most prominent clinical feature. Over the years, there has been a growing recognition for the strong association between seropositivity of several myositis-specific antibodies (MSAs) and lung involvement. Growing literature suggests that individual MSAs may influence the risk of developing ILD and are associated with pulmonary disease severity and various clinical sub-phenotypes. The presence of ILD in patients with myositis correlates with increased morbidity and mortality. As such, it presents a unique treatment challenge for both the rheumatology and pulmonary communities and requires a multidisciplinary approach to management. This review will discuss the role of serologies and invasive and non-invasive testing modalities utilised to diagnose and monitor patients with myositis-ILD. Current studies pertaining to the wide array of immunomodulatory therapies utilised in cases of progressive disease are also highlighted in detail.

High-flow nasal cannula for reducing hypoxemic events in patients undergoing bronchoscopy: A systematic review and meta-analysis of randomized trials

BACKGROUND

Patients undergoing bronchoscopic procedures may develop hypoxemia and severe complications. High-flow nasal cannula (HFNC) may prevent hypoxemic events during bronchoscopy. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the effectiveness of HFNC in these patients.

METHODS

We conducted a search in PubMed, Embase, and the Cochrane Library for RCTs published before November 2021. Individual effect sizes were standardized, and a meta-analysis was performed to calculate the pooled effect size using random-effects models. The primary outcome was the incidence of hypoxemic events (oxygen saturation [SpO2] < 90%) during bronchoscopy. Secondary outcomes included the incidence of interrupted bronchoscopy due to desaturation, lowest SpO2 during bronchoscopy, partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), end-tidal CO2 (EtCO2) at the end of bronchoscopy, and the incidence of intubation after the procedure.

RESULTS

Five trials involving 257 patients were reviewed. The incidence of hypoxemic events was lower in the HFNC group than in the conventional oxygen therapy group (risk ratio, 0.25; 95% confidence interval [CI], 0.14-0.42). The lowest SpO2 during the procedure was significantly higher in the HFNC group than in the conventional oxygen therapy group (weighted mean difference [WMD], 7.12; 95% CI, 5.39-8.84). PaO2 at the end of the procedure was significantly higher in the HFNC group than in the conventional oxygen therapy group (WMD, 20.36; 95% CI, 0.30-40.42). The incidence of interrupted bronchoscopy due to desaturation, PaCO2 and EtCO2 at the end of the procedure, and the incidence of intubation after the procedure were not significantly different between groups.

CONCLUSIONS

HFNC may reduce the incidence of hypoxemic events and improve oxygenation in patients undergoing bronchoscopy.

High-flow nasal cannula oxygen therapy for outpatients undergoing flexible bronchoscopy: a randomised controlled trial

INTRODUCTION

High-flow nasal cannula (HFNC) provides benefits to patients undergoing flexible bronchoscopy (FOB). We compared the effects of HFNC versus standard therapy (ST) on gas exchange, lung volume and diaphragm function in patients undergoing FOB for bronchoalveolar lavage (BAL).

METHODS

36 outpatients were randomised to ST or HFNC. Arterial blood gases, episodes of severe desaturation, changes of end-expiratory lung impedance (ΔEELI), diaphragm ultrasound were recorded. Measurements were done at baseline (T0), after bronchoscope insertion (T1), at the end of the procedure (T2) and 10 min afterwards (T3).

RESULTS

Arterial partial oxygen pressure (PaO₂) was not different between T0 (10.8 (95% CI 8.7 to 12.0) kPa and T2 (11.1 (95% CI 10.4 to 12.0) kPa) with HFNC, while decreased from 11.1 (95% CI 10.5 to 12.1) to 9.1 (95% CI 8.4 to 9.8) kPa with ST. At T2, PaO₂ was significantly higher with HFNC than with ST (p<0.001). Also, with HFNC, compared with ST, fewer desaturations occurred (11% vs 56%; p<0.01). ΔEELI was no different at the different time points with HFNC, while with ST there was a significant decrease at T1 (-170 (95% CI -382 to -32) mL, p=0.003), T2 (-211 (95% CI -425 to -148) mL, p<0.001) and T3 (-213 (95% CI -398 to -81) mL, p<0.001), as opposed to T0. EELI was lower with ST than HFNC at T1 (p=0.006), T2 (p=0.001) and T3 (p=0.002). Diaphragm displacement was no different between groups (p=0.748), while the thickening fraction significantly increased at T1 and T2 with ST only (p<0.01).

CONCLUSIONS

During FOB for BAL, HFNC improves gas exchange, avoiding loss of end-expiratory lung volume and preventing increase of diaphragm activation.

TRIAL REGISTRATION NUMBER

NCT04016480.

Bronchoscopic performance of bronchoalveolar lavage in germany - a call for standardization

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).

Conclusion:

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.

Correlation of bronchoalveolar lavage lymphocyte count with the extent of lung fibrosis and with plethysmographic lung volumes in patients with newly recognized hypersensitivity pneumonitis

Introduction

Hypersensitivity pneumonitis (HP) is an increasingly recognized interstitial lung disease, presenting with elevated total cell counts and high percentage of lymphocytes in bronchoalveolar lavage fluid (BALF). Despite many publications, there is no consensus in the literature concerning BALF cellular composition in patients with prolonged course of HP.

Aim

The aim of the present retrospective study was to investigate the influence of disease duration, smoking habits, and the extent of lung fibrosis on BALF cells’ population in patients with newly recognized HP.

Material and methods

In total, 94 patients (49 females, 45 males), mean age 52 (±12) years, with HP recognized according to recently proposed criteria, were enrolled into the present study. Chest CT scans were retrospectively reviewed by two independent radiologists. BALF evaluation was performed as a part of routine diagnostics according to recent recommendations.

Results

Percentage of lymphocytes in BALF was significantly lower in patients with lung fibrosis (stage 1 and 2) comparing to those without lung fibrosis (stage 0). Significant correlation was also found between the percentage of BALF lymphocytes and plethysmographic lung volumes, but not with lung transfer capacity for carbon monoxide (TLCO% pred). Smoking did not influence BALF results in our study group.

Conclusions

BALF lymphocytosis correlated with the presence and the extent of lung fibrosis on chest CT as well as with plethysmographic lung volumes but did not with TLCO and smoking habits in newly recognized HP pneumonitis.

Transbronchial Cryobiopsy in Interstitial Lung Diseases: State-of-the-Art Review for the Interventional Pulmonologist

Interstitial lung diseases are a heterogenous group of disorders that are often difficult to diagnose precisely. Clinical, laboratory, radiographic, and histologic information may be needed to arrive at the correct diagnosis. The multidisciplinary discussion has been proven to be useful in this patient group. Transbronchial cryobiopsy has become a popular method for obtaining tissue samples. Over the course of the last decade, there has been a significant amount of research assessing the feasibility, safety, and diagnostic endpoints of transbronchial cryobiopsy in patients with interstitial lung disease. Data continues to mount to support its use, which has been reflected in guidelines and expert panel reports. Patient selection, procedural performance, and appropriate specimen handling are critical factors for success. A coordinated approach by pulmonologists with expertise in interstitial lung diseases, interventional pulmonologists, and thoracic pathologists is essential. In this evidence-based narrative review, we address transbronchial cryobiopsies from these three distinct perspectives. In addition, the current literature was used to address nine common procedural questions.

Cytological analysis of bronchoalveolar lavage fluid in asbestos-exposed workers

Background:

Asbestos-related lung diseases are a group of heterogeneous disorders with different pathogenesis and prognosis. Very few studies investigated the BALF cell profile of asbestos exposed workers. The existence of a relationship between bronchoalveolar lavage fluid (BALF) cellular pattern and specific diagnosis and/or asbestos exposure biomarkers would allow the identification of effect biomarkers useful in the follow up of asbestos-exposed workers and in the diagnosis of asbestos-related diseases.

Objectives:

To assess BALF cell profile in formerly asbestos-exposed workers and its relationship with asbestos fibre (amphibole and chrysotile) and asbestos body (AB) concentrations.

Methods:

113 male workers formerly exposed to asbestos underwent bronchoscopy with bronchoalveolar lavage and were retrospectively enrolled. 35 of them were affected by pleural plaques and 10 were affected by asbestosis. Pulmonary functional tests (PFT), BALF cellular pattern, BALF mineralogical analysis with asbestos fibres and AB counting were performed in each patient. A statistical analysis with a multivariate linear regression model was adopted.

Results:

From the statistical analysis of data a direct correlation between pack-years and BALF macrophages was found. Inversely correlation between pack-years and BALF lymphocytes was detected. There was not relationship among BALF cellular pattern, PFT values, specific diagnosis, BALF AB count or BALF asbestos fibre concentration.

Discussion:

BALF cellular pattern does not seem to be related to asbestos exposure biomarkers like AB and asbestos fibre concentration in BALF. Instead, smoke habit can induce an increase in BALF macrophages and a decrease of BALF lymphocytes count.

Outcomes of patients with a non-diagnostic initial bronchoscopy for suspected thoracic malignancy

Lung cancer is 1 of the leading causes of cancer-related deaths and bronchoscopy is an essential tool for the diagnosis. The diagnostic yield varies based on the characteristics of the lesion and bronchoscopic techniques employed. There is limited data regarding outcomes of patients suspected of thoracic malignancies with a non-diagnostic initial bronchoscopy. The goal of the study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy for suspected thoracic malignancies and to evaluate variables predictive of a diagnostic bronchoscopy.Retrospective analysis of adult patients at BronxCare Hospital Center who underwent bronchoscopy for suspected thoracic malignancy. The study period was January 2012 to February 2019. Exclusion criteria included patients who underwent only inspection bronchoscopy or bronchoalveolar lavage as the diagnostic yield for malignancy with these techniques is low. All other bronchoscopic procedures were included that is, endobronchial biopsies, transbronchial biopsies, and endobronchial ultrasound guided-transbronchial needle aspiration. Bronchoscopy was considered diagnostic when a specific histopathological diagnosis was established.311 patients underwent bronchoscopy to rule out malignancy. A diagnosis was obtained in 153 (49.2%) patients, 81 (52.9%) had primary lung cancer and 14 (9.15%) other malignancies. 158 (50.8%) patients had initial non-diagnostic bronchoscopy; 86 (54.43%) were lost to follow up. Of the remaining 72 (45.57%) patients, radiological resolution or stability was observed in 51 (70.8%) patients. Primary lung cancer was found in 13 (18.05%) patients and other malignancies in 5 (6.94%). Predictive of a diagnostic bronchoscopy was the performance of endobronchial biopsies and endobronchial ultrasound guided-transbronchial needle aspiration.This study highlights some of the barriers to the timely diagnosis of thoracic malignancies. Following patients with a non-diagnostic procedure as well as all those patients with diagnosed malignancies it of the utmost importance. In patients available for follow up, close to 25% of additional cases with treatable malignancy could be identified and patients diagnosed with cancer could receive timely treatment.

Diagnostic approach in parenchymal lung diseases: transbronchial lung biopsy or cryobiopsy?

Background/aim

Diagnosis of interstitial lung diseases requires a multidisciplinary approach, and a gold standard for histological diagnosis is open lung biopsy. Transbronchial lung biopsy (TBLB) and in recent years an alternative method, cryobiopsy (TBLC), are used for the diagnosis of parenchymal lung lesions. The aim of this study is to compare the efficacy of concomitant conventional TBLB and TBLC.

Materials and methods

A total of 82 patients who underwent TBLC for diagnosis of diffuse parenchymal lung diseases at Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital between 2015 and 2018 were screened retrospectively and included in the study. Of the patients, 53.7% (n: 44) were male, and 46.4% (n:38) of them were female. The mean age was 58.37 (±9.33) years. First TBLB and then TBLC were performed to all patients in the same session and their diagnostic performances were compared.

Results

Although both procedures were done in the same session, 45 patients (54.9%) were diagnosed with TBLB and 75 patients (91.5%) were diagnosed with TBLC (P ˂ 0.001). Hemorrhage was observed in 39 patients (47.6%), but only one had a massive hemorrhage. Pneumothorax was observed in 6 patients (7.3%) and none of them required tube drainage.

Conclusion

Transbronchial lung cryobiopsy is a promising technique for the diagnosis of parenchymal lung diseases compared to transbronchial lung biopsy. 

Exploratory Study of a CT Radiomics Model for the Classification of Small Cell Lung Cancer and Non-small-Cell Lung Cancer

Background: Radiomics can quantify tumor phenotypic characteristics non-invasively by applying feature algorithms to medical imaging data. In this study, we investigated the association between radiomics features and the tumor histological subtypes, and we aimed to establish a nomogram for the classification of small cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). Methods: This was a retrospective single center study. In total, 468 cases including 202 patients with SCLC and 266 patients with NSCLC were enrolled in our study, and were randomly divided into a training set (n = 327) and a validation set (n = 141) in a 7:3 ratio. The clinical data of the patients, including age, sex, smoking history, tumor maximum diameter, clinical stage, and serum tumor markers, were collected. All patients underwent enhanced computed tomography (CT) scans, and all lesions were pathologically confirmed. A radiomics signature was generated from the training set using the least absolute shrinkage and selection operator algorithm. Independent risk factors were identified by multivariate logistic regression analysis, and a radiomics nomogram based on the radiomics signature and clinical features was constructed. The capability of the nomogram was evaluated in the training set and validated in the validation set. Results: Fourteen of 396 radiomics parameters were screened as important factors for establishing the radiomics model. The radiomics signature performed well in differentiating SCLC and NSCLC, with an area under the curve (AUC) of 0.86 (95% CI: 0.82-0.90) in the training set and 0.82 (95% CI: 0.75-0.89) in the validation set. The radiomics nomogram had better predictive performance [AUC = 0.94 (95% CI: 0.90-0.98) in the validation set] than the clinical model [AUC = 0.86 (95% CI: 0.80-0.93)] and the radiomics signature [AUC = 0.82 (95% CI: 0.75-0.89)], and the accuracy was 86.2% (95% CI: 0.79-0.92) in the validation set. Conclusion: The enhanced CT radiomics signature performed well in the classification of SCLC and NSCLC. The nomogram based on the radiomics signature and clinical factors has better diagnostic performance for the classification of SCLC and NSCLC than the simple application of the radiomics signature.

An update on the role of bronchoscopy in the diagnosis of pulmonary disease

Bronchoscopy has evolved over the past few decades and has been used by respiratory physicians to diagnose various airway and lung diseases. With the popularization of medical check-ups and growing interest in health, early diagnosis of lung diseases is essential. With the development of endobronchial ultrasound, ultrathin bronchoscopy, and electromagnetic navigational bronchoscopy, bronchoscopy has been able to widen its scope in diagnosing pulmonary diseases. In this review, we have described the brief history, role, and complications of bronchoscopy used in diagnosing pulmonary lesions, from simple flexible bronchoscopy to bronchoscopy combined with several up-to-date technologies.

The significance of multidisciplinary classifications based on transbronchial pathology in possible idiopathic interstitial pneumonias

Surgical lung biopsy is regarded as the golden standard for the diagnosis of idiopathic interstitial pneumonias (IIPs). Here, we attempted to show the diagnostic accuracy of multidisciplinary classifications based on transbronchial pathology including transbronchial lung cryobiopsy (TBLC) , bronchoalveolar lavage fluid (BALF) and endobronchial ultrasound-guided transbronchial needle aspiration biopsy (EBUS-TBNA).Patients with suspected interstitial lung diseases admitted from June 1, 2016 to December 31, 2018 were involved. Patients with known causes of interstitial lung diseases and typical idiopathic pulmonary fibrosis diagnosed through clinical, radiological information were excluded. Patients with atypical idiopathic pulmonary fibrosis and possible IIPs accepted transbronchial pathological evaluation. Initial multidisciplinary diagnosis (MDD) classifications were made depending on clinical, radiological and transbronchial pathological information by a multidisciplinary team (MDT). The final MDD classifications were confirmed by subsequent therapeutic effects. All patients were followed up for at least 6 months.A total of 70 patients were finally involved. The samples of lung parenchyma extracted through TBLC were enough for confirmation of pathological diagnoses in 68.6% (48/70) cases. Samples of 6 cases were extracted by EBUS-TBNA. Bacteriological diagnoses were positive in 1 case by BALF. Pathological diagnoses of 77.1% (54/70) cases were achieved through TBLC, EBUS-TBNA and BALF. During the follow up study, the pulmonary lesions of 60% patients were improved, 11.43% were relapsed when glucocorticoid was reduced to small dose or withdrawal, 14.29% were leveled off and 8.57% were progressed. The diagnoses of 4 patients with progressed clinical feature were revised. As a result, 94.3% initial MDD classifications based on transbronchial pathology were consistent with the final MDD, and the difference of diagnostic yield wasn't significant between initial and final MDD (Z = -1.414, P = .157).Classifications of IIPs based on transbronchial pathology were useful and quite agreed with final MDD.

Bronchoscopic sampling techniques in the era of technological bronchoscopy

Flexible bronchoscopy is a key diagnostic and therapeutic tool. New endoscopes and technologically advanced navigational modalities have been recently introduced on the market and in clinical practice, mainly for the diagnosis of mediastinal lymph adenopathies and peripheral lung nodules. Bronchoscopic sampling tools have not changed significantly in the last three decades, with the sole exception of cryobiopsy. We carried out a non-systematic, narrative literature review aimed at summarizing the scientific evidence on the main indications/contraindications, diagnostic yield, and safety of the available bronchoscopic sampling techniques. Performance of bronchoalveolar lavage, bronchial washing, brushing, forceps biopsy, cryobiopsy and needle aspiration techniques are described, focusing on indications and diagnostic accuracy in the work-up of endobronchial lesions, peripheral pulmonary abnormalities, interstitial lung diseases, and/or hilar-mediastinal lymph adenopathies. Main factors affecting the diagnostic yield and the navigational methods are evaluated. Preliminary data on the utility of the newest sampling techniques (i.e., new needles, triple cytology needle brush, core biopsy system, and cautery-assisted transbronchial forceps biopsy) are shown. TAKE HOME MESSAGE: A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.

Usefulness of bronchoalveolar lavage in a French pediatric cohort with hypersensitivity pneumonitis

BACKGROUND

Hypersensitivity pneumonitis (HP) is a rare interstitial lung disease in children, and very little data are available on the frequency, diagnosis, and outcomes of HP. In a pediatric cohort with HP, the characteristics of the CD4/CD8 lymphocyte ratio are often described as nonspecific.

METHODS

We used the National French Database (RespiRare) to collect data from the last decade on HP. The diagnosis of HP was defined by the presence of a relevant exposure, clinical symptoms, and compatible lung imaging radiology and was usually defined by positive precipitins antibodies.

RESULTS

A total of 16 children with a mean age of 10 years (4-13) presented with HP. All children presented with dyspnea on exertion. Diffuse ground-glass opacity was present in all computed tomography (CT) scans. Research guided by a questionnaire and precipitins antibodies against the corresponding antigens showed that patients were positive for contact with birds with or without fungi. Bronchoalveolar lavage (BAL) was performed in 12 children. The total cell counts were elevated in BAL fluid, with a mean value of 36% lymphocytes. The CD4/CD8 lymphocyte ratio was below one for all children.

CONCLUSION

BAL in our pediatric cohort with HP had the same characteristics as that of adults with HP. An HP diagnosis must be considered when dyspnea on exertion and diffuse ground-glass opacity are observed. Carrying out BAL and serological tests can help diagnose and avoid lung biopsy.

Surgical management of organizing pneumonia: a retrospective study of 24 cases in a single Centre

Background

Organizing pneumonia (OP) is a rare disease that is often easily misdiagnosed as a malignancy. The diagnosis of OP can prove quite challenging. Patients typically receive treatment with high-dose corticosteroids. Relapse is common if corticosteroid treatment is reduced or stopped. However, given that long-term corticosteroid treatment often results in significant side-effects, the aim of this study was to discuss the diagnosis and surgical treatment of OP.

Material and methods

The medical records of 24 patients with pathologically diagnosed OP between October 2007 and January 2019 were retrospectively reviewed. All patients underwent thoracic computed tomography (CT) and transbronchial biopsy or CT-guided percutaneous needle aspiration. We analysed the clinical manifestations, radiological findings, diagnostic methods, treatment, and follow-up outcomes of all patients.

Results

In total, 24 patients with OP were identified. The study included 17 (70.8%) men and 7 (29.2%) women, and the mean age was 61.25 ± 11.33 years (range: 31–82). The most common symptom was cough (n = 16; 66.6%), and the most common radiological finding was consolidation (n = 13; 54.2%) on thoracic CT. The diagnosis of OP was made by transbronchial biopsy in 11 patients (45.8%), and percutaneous needle aspiration biopsy in 13 (54.2%). We performed 11 wedge resections, 9 segmentectomy, and 4 lobectomies. Twenty patients underwent video-assisted thoracoscopic surgery (VATS), and 4 underwent thoracotomy. Complete lesion resection was obtained in all patients, and all patients were discharged from the hospital between 5 and 11 days after surgery. The mean follow-up period was 59.1 ± 34.5 (range: 2–134) months. Residual lesions or local or distant recurrence were not observed.

Conclusions

OP is a rare disease, and the exact aetiology remains unclear. Preoperative diagnosis is difficult to achieve despite the use of transbronchial biopsy or CT-guided percutaneous needle aspiration. Complete surgical resection represents an effective method for the treatment of OP.

Outcomes of patients with non-diagnostic bronchoscopy: A clinico-radiological comparison of patients with diagnostic and non-diagnostic bronchoscopy

Bronchoscopy is one of the most common diagnostic procedures in pulmonary practice. Data on the outcome of patients following a non-diagnostic bronchoscopy are sparse. Diagnostic yield depends on indication, the characteristics of patients, and the chest imaging. The aim of this study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy and to compare patients who had a diagnostic with those that had a non-diagnostic bronchoscopy.Retrospective, single-center study of adult patients who underwent bronchoscopy with transbronchial biopsy (TBBX) and/or endobronchial biopsy (EBBX), endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), or brushing. A strict definition for a "diagnostic" bronchoscopy was used. Univariate and multivariate analyses were performed.A total of 684 patients were identified, 350 (51%) had a diagnostic procedure. Of the 334 patients with a non-diagnostic bronchoscopy, 196 (58.6%) were followed, but only 172 (88%) completed 1 year of follow-up. Most of the patients (57.8%) had resolution or stabilization of the condition; in the remaining patients, malignancy was most commonly diagnosed after further investigation followed by diffuse lung diseases and infections. Pulmonary tuberculosis was diagnosed in 8 patients. EBUS-TBNA and EBBX were the procedures associated with a diagnostic bronchoscopy. Presence of bilateral interstitial infiltrates predicted a non-diagnostic bronchoscopy.A significant number of patients with non-diagnostic bronchoscopy may have serious treatable disease that is identified upon further investigation. Close follow up of patients with a non-diagnostic procedure is warranted. Our study found no clear clinical or radiological predictors of diagnostic bronchoscopy.

Correlation between the Diagnostic Yield from the Bronchoalveolar Lavage Fluid Analysis and Clinicoradiological Findings in Sarcoidosis

OBJECTIVES

The diagnosis of sarcoidosis is frequently challenging, requiring a search for less invasive, more reliable diagnostic methods. The bronchoalveolar lavage fluid (BALF) analysis has been used in the differential diagnosis of sarcoidosis for many years with a wide sensitivity and specificity rates. The objective of the study is to investigate whether diagnostic performance of the BALF analysis is altered by clinicoradiological findings of patients with sarcoidosis.

MATERIALS AND METHODS

The present study is a retrospective, single-center, observational study, designed in a sarcoidosis outpatient clinic in a training hospital. Patients who had undergone the bronchoalveolar lavage BAL procedure at diagnosis were included in the study. Demographics, clinical and detailed chest X-ray, and high-resolution computed tomography (HRCT) findings at diagnosis were recorded. According to the diagnostic performance, the BALF results were grouped as "diagnostic" and "non-diagnostic," and recorded parameters were compared between the groups.

RESULTS

Considering the BALF analysis of all the 257 patients, the mean lymphocyte ratio was 41±17.5 (5-80), and the mean CD4/CD8 was 5.5±4.7 (0.1-24.7). The BALF analysis was diagnostic in 56% (n=145) of patients. Diagnostic performance of the procedure did not correlate with any of the demographic data, smoking status, spirometric findings, chest X-ray staging, HRCT findings, and tomography scoring. Extrapulmonary involvement was significantly more frequent in the diagnostic group (66% vs. 34%, p=0.006).

CONCLUSION

BALF results signal sarcoidosis in more than half of the patients. The diagnostic role of BALF is greater in patients with extrapulmonary involvement.