BRONCHIAL WASHINGS AND BAL

FLUID EXAMINATION
IN
PULMONARY PATHOLOGY

PRESENTER- DR. ANUBHUTI JAIN

MODERATOR- DR.R.K.NIGAM
 Bronchoscopic Techniques

BAL is performed by the placement of the bronchoscope

into an affected lung segment. After wedging, 150 mL of
sterile normal saline is instilled followed by the recovery
of the specimen in a sterile container.

BW is performed by the placement of the bronchoscope

into an airway of an affected lung lobe and collection of
specimens following the instillation of one to three
aliquots of 10 mL sterile normal saline.
 Handling of Aspirated Fluid

At the time of the lavage cells should be stored in

silicone-coated containers.

Cell counts should be made preferably**

on unfiltered, unwashed, and un-concentrated
samples.
 Satisfactory Sample : Criteria

1. Minimum requirement

2×106 cells
>10 macrophages in a hpf

2. Degenerative changes should cover <20%

3. Number of squamous epithelial cells, bronchial

cells, RBCs, or inflammatory cells less than
macrophages.
NORMAL ANATOMY
 NORMAL HISTOLOGY
Parts Mucosal lining

Nasal vestibules Stratified squamous epithelium

Nasal sinuses Ciliated columnar epithelium

Nasopharynx Ciliated columnar epithelium

Larynx Mostly : Ciliated columnar epithelium

Vocal cords and superior surfaces of the
epiglottis: Stratified squamous epithelium

Trachea and bronchi Ciliated columnar epithelium, goblet cells,

neuroendocrine cells

Terminal bronchioles Simple columnar to cuboidal epithelium

Alveoli Type I and II pneumocytes and alveolar

macrophages
NORMAL CYTOLOGY

Acellula
Cellular
r
material
material
Lining cells Curschmann’s spirals
Squamous epithelial cells Ferruginous (asbestos)
Ciliated columnar cells bodies
Alveolar macrophages Charcot-Leyden
crystals
Goblet cells
Carbon particles
Hemosiderin
Associated cells
Polymorphs Contaminants
Lymphocytes Pollen grains
Histiocytes Vegetable materials
Contaminants from food
particles
 (A) CELLULAR MATERIAL

Squamous Epithelial Cells

Come from the oral cavity as contaminants

The cells are superficial squamous cells

Columnar Cells
Predominant lining cells of the lower respiratory tract.
Goblet cells-

Present in small clusters

Cells with moderate amount of vacuolated

cytoplasm

Round, monomorphic nuclei

Abundant goblet cells seen in bronchial

asthma, chronic bronchitis
Alveolar Macrophages

“key cells” indicate adequacy

 Present singly

 Round cells with abundant cytoplasm

filled with brownish to blackish dust
particles.

 Centrally placed kidney-shaped nuclei

Material Morphology Significance
(B) ACELLULAR
Curschmann’s Spirals
MATERIAL
Corkscrew-shaped long chronicbronchitis,
mucus cast asthma
smokers

Ferruginous (asbestos) Long rod-shaped golden- asbestos exposure

bodies brown structures with two
terminal bulbous tips

Charcot-Leyden Bi-pyramidal needle- shaped Asthma,

crystals crystal with two pointed ends eosinophilic pneumonia
and allergic
bronchopulmonary
aspergillosis

Mucus Acellular homogenous Bronchial obstruction

substances and bronchioloalveolar
carcinoma
 BENIGN CELLULAR ABNORMALITIES

 Squamous cells

 Bronchial epithelium

 Reserve cell hyperplasia

 Hyperplasia of type II pneumocytes

 Abnormalities of Squamous Cells

Inflammatory Changes

Mild nuclear enlargement and hyperchomasia.

Nuclei show degenerative changes.

In contrast to malignant cells, the cells show

regular nuclear membrane and monomorphic
nuclei.
 Abnormalities of Bronchial Epithelial Cells

1. Ciliocytophoria

 Viral infection of the bronchial lining epithelial cells cause detachment

of cilia from the cell. This condition is known as ciliocytophoria.

 There is no association of malignancy with ciliocytophoria**.

 2. Hyperplastic Bronchial Epithelium

 Nuclear enlargement and pleomorphism.

 Prominent nucleoli and clumped chromatin.

 Large 3-D papillary clusters of the bronchial cells

with smooth peripheral outline.

 The cells are small with monomorphic nuclei,

fine nuclear chromatin and prominent nucleoli.
This cluster of cells is also called as Creola body.

 May be mistaken for adenocarcinoma due to the

papillary arrangement of the cells.
 Bronchial Reserve Cell Hyperplasia

Tight cohesive small clusters

Small cells

High N/C ratio

Scanty cytoplasm

Hyperchromatic nuclei
 Hyperplasia of Type II Pneumocytes

Tight papillary clusters

Abundant vacuolated
cytoplasm

Enlarged nuclei

Prominent nucleoli
INFECTIONS

Bacterial

Fungal

Viral

Parasitic
 Bacterial Infections

Tuberculosis

 This is granulomatous inflammation.

 The cytology smear shows

multinucleated giant cells, epithelioid
cell granulomas, lymphocytes and
necrosis.

 Pathognomonic for tuberculosis.

Actinomycosis

 Commonly present in tonsilar crypts and gingival crevices.

 They infect lung in anaerobic condition such as lung injury or infarct.
 The organisms are cotton ball-like floppy hemtoxylin-stained tangled
filamentous material with associated squamous cells.
Nocardia

Nocardia is the aerobic

filamentous organisms and is
inhabitant of soil.

Infect lung in the

immunocompromised patient.

Nocardia is slender, filamentous,

branching organisms.
 Fungal Infections

The smears usually show multinucleated giant cells,

epithelioid cell granulomas, polymorphs and
eosinophils along with necrotic material.
 Zygomycetes

Aspergillus:
Cryptococcus:
 Viral Infection

Herpes Virus Infection

 The individual cells shows-

 Multiple enlarged basophilic nuclei with

ground-glass appearance,
 Large intranuclear eosinophilic inclusions.
 Nuclei of the giant cells are molded.
 Cytomegalovirus

 Large amphophilic intranuclear

inclusion with a peripheral clear
halo.

 Small satellite basophilic

cytoplasmic inclusions are seen.

 Adenovirus:

 The cytology smears show cilliocytophoria of the respiratory epithelial

cells.

 The virus affected cells show two types of inclusions.

1. Small reddish well-circumscribed inclusion surrounded by clear halo
2. Large basophilic homogenous inclusion that fills the entire nucleus.
 Measles Virus

 RNA virus and commonly infects children.

 Multinucleated giant cells (Warthin-Finkelday cells) with more than

100 nuclei containing eosinophilic intracytoplasmic and
intranuclear inclusions.
 Parasitic Infection

Strongyloidiasis

It comes to the lung through

hematogenous migration from the
intestine or skin.

The larvae are long, 400 microns

in length with a characteristic V-
shaped notch in the tail.
Features Reactive Malignant cells
atypical
bronchial cells
Cell arrangement Predominantly Dissociated cells
tight papillary
clusters
Margin of the Smooth Irregular
cluster
Nuclear crowding No significant Nuclear
nuclear overlapping
overlapping
Atypical cells Scanty Many
Nuclear margin Regular Irregular
Nuclear chromatin Fine Irregular
coarsely
clumped
MALIGNANT ABNORMALITIES

Lung Cancer Carcinoid

Lung Mets
 Squamous Cell Carcinoma

Polyhedral cells (tadpole cells)

Intracellular keratin (orangeophilic

cell eosinophilic cytoplasm)

Round nucleus with moderate

nuclear pleomorphism

Hyperchromatic nucleus,
inconspicuous nucleoli

Background necrosis and granular

debris.
Adenocarcinoma of lung
 Small cell carcinoma

Dissociated cells

Small cells resembling

lymphocytes

Scanty cytoplasm

Hyperchromatic nucleus with

inconspicuous nucleoli

Paranuclear blue body

 Undifferentiated large cell carcinoma

 Large cell with marked nuclear

pleomorphism

 Moderate to abundant Ill-

defined cytoplasm

 Severely pleomorphic bizarre

nuclei

 Multiple prominent nucleoli

 Polymorphs sticking to the cells

 Carcinoid

Dissociated cells

Monomorphic cells

Moderate to abundant
cytoplasm with red
granularity
 Metastatic Malignancies

Most common site of metastasis.

Uncommonly seen in sputum, bronchial washing or brushing specimen.

Most common primary sites of metastatic lung carcinomas are

breast,
colon,
stomach,
pancreas,
kidney,
prostate,
liver
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