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Updated: Jun 8, 2026
Bronchoalveolar Lavage (BAL) for Research; Obtaining Adequate Sample Yield
Published on: March 24, 2014
Bronchoalveolar lavage in children with cystic fibrosis: how many lobes should be sampled?
F J Gilchrist1, S Salamat, S Clayton
1Academic Department of Child Health, University Hospital of North Staffordshire, Stoke-on-Trent, UK. fjgilchrist@hotmail.com
Insights
Bronchoalveolar lavage (BAL) in children with cystic fibrosis (CF) requires samples from multiple lobes. A single BAL sample is insufficient, and even two samples may miss infections, impacting lower airway infection assessment in CF patients.
Area of Science:
- Pediatric Pulmonology
- Infectious Diseases
- Respiratory Medicine
Background:
- European Respiratory Society (ERS) guidelines for bronchoalveolar lavage (BAL) in children were updated in 2007 for cystic fibrosis (CF) patients, recommending two samples.
- Previous guidelines (2000) recommended a single BAL specimen.
Purpose of the Study:
- To evaluate if bronchoalveolar lavage (BAL) samples from one or two lobes adequately detect lower airway infections in pediatric cystic fibrosis (CF) patients.
- To assess the diagnostic yield of single versus multiple lobe BAL sampling in CF.
Main Methods:
- Retrospective review of 39 flexible bronchoscopies in 31 pediatric CF patients (May 2007 - May 2009).
- BAL specimens were collected from all six lobes for each procedure.
- Analysis compared results from single-lobe and two-lobe sampling against six-lobe sampling to identify missed positive cultures.
Main Results:
- Sampling from only one lobe would have missed 26 positive cultures (14 organisms) in 11 patients.
- Sampling from two lobes would have missed 12 positive cultures (8 organisms) in 7 patients.
- A significant number of infections were missed with one or two BAL samples.
Conclusions:
- Single-lobe bronchoalveolar lavage (BAL) is inadequate for diagnosing lower airway infections in pediatric cystic fibrosis (CF) patients.
- Even two-lobe BAL sampling may fail to identify all causative organisms, potentially delaying appropriate treatment.
Background:
The European Respiratory Society guidance on bronchoalveolar lavage (BAL) in children was published in 2000. It recommended taking one BAL specimen from the most affected lobe or from the right middle lobe in diffuse disease. In 2007, the European Respiratory Society modified the recommendations for children with cystic fibrosis (CF), suggesting two BAL specimens (right middle lobe and the lingula or the most affected lobe).
Objective:
To determine if BAL samples from one or two lobes give the full picture of lower airway infection in children with CF.
Design, Setting And Patients:
A retrospective review of all paediatric patients with CF who underwent flexible bronchoscopy between May 2007 and May 2009 was undertaken.
Main Outcome Measures:
As BAL specimens from all six lobes were collected, the BAL results were reviewed to identify if positive cultures would have been missed if only one lobe (right middle or most affected) or two lobes (right middle plus the lingula or most affected) had been sampled.
Results:
The results of 39 bronchoscopic procedures in 31 children were reviewed. The BAL samples were taken from 6 lobes in all 39 procedures. Had only one lobe been used, 26 positive cultures (14 organisms) would have been missed in 11 patients. Had two lobes been used, 12 positive cultures (8 organisms) would have been missed in 7 patients.
Conclusion:
A single-lobe BAL is insufficient in assessing patients with CF for lower airway infection. Even when BAL specimens are taken from two lobes, a number of infections may be missed.
