Bronchial lava. Bronchoalveolar lava

- Diagnostic procedure, the essence of which is the introduction into bronchi, light animal sterile mortar, in its further removal, as well as the study of the cells of the obtained sample, determining the sensitivity of the microorganism to antibiotics.

For diagnostics, a bronchoscope is used, which allows the doctor to be able to evaluate the respiratory tract in detail and take an analysis from the damaged area.

Ball is a therapeutic procedure. Many pets after the procedure, the respiratory function is significantly improved.

Bronchoscopy, together with the fence of wasches in veterinary practice, is used often. Bronchoscopy makes it possible to establish the degree of inflammation, bronchootasia, respiratory collaboration, tumor defeat. Washing fence - to estimate the character of inflammation on the cellular composition of the liquid, to carry out a microbiological research in order to detect the pathogen.

Features of diagnostics, indications, symptoms: method efficiency

Fence of the fluid is performed from the bronchi, bronchiol, the patient's alveoli. As a result, the doctor receives detailed information about the work of the bronchi and the lungs.

Most of diseases of the lower respiratory tract has similar symptoms. Exceptionally according to physical examination (inspection of the animal, listening to the lungs), the veterinarian cannot establish an accurate diagnosis. Then how the light radiography can reveal the inflammation of the bronchi, the degree of defeat. However, the nature of the pathological process is not possible to establish due to it.

The ball allows you to distinguish between allergic, infectious, tumor problems. This method is sufficiently informative if long-term infectious bronchitis is observed, since it allows you to quickly select the appropriate drug, as efficiently impact on the causative agent.

Bronchoalveolar lavage in dogs and other animals are performed using a rigid bronchoscope with general anesthesia.

Diseases in which presented diagnostics are necessary:

The main symptoms when inflammation of the respiratory tract, collapse:

• Chronic unproductive cough;
• Dyspnea;
• Suffocation;
• Chianosis of mucous
• Intolerance to loads;
• Lost.

Technique of the ball: diagnostic accuracy

The study is performed under general anesthesia. The process takes a little time (about 10 minutes). The procedure is absolutely painless, although some pets can be discomfort after the fence wash. After the ball, the clinical picture of the disease becomes better (breathing improves, cough intensity decreases).

At the rate of 0.5 ml per 1 kg of the weight of the animal is poured sterile solution. Then quickly aspirated back. Good result - getting a back 50% volume. The remaining part is absorbed by the mucous respiratory tract.

About 15 minutes after the procedure, a thorough home pet monitoring is performed for a respiratory distress, mucous cyanosis. The animal quickly comes back and returns the owner on the same day.

The results of microbiological and cytological studies are preparing up to 7 business days. Thus, the ball is an informative study that allows you to make a diagnosis accurately, as well as quickly choose treatment for your pet.

The need and safety of the ball: the professional approach of veterinarians "Height" clinic

It is important to understand a long-term chronic progressive cough may indicate the development of heavy bronchopulmonary diseases that are difficult to treat.

For example, asthma cat is distinguished by a high risk of fatal outcome. Therefore, the bronchoalveolar lavage in cats will allow the diagnosis in a timely and accurately, as well as pick up therapy that will allow early stage Solve the problem and improve the quality of life of a pet.

The ball is considered to be safe and effective in identifying the diagnosis by the method. It provides therapeutic effect. After the procedure, the disappearance of cough is characteristic. Requires minimal anesthesia. When conducting training does not have side effects.

- This is a bronchoscopic method of obtaining washes from the surface of the smallest bronchi (bronchiole) and alveolar lung structures for cytological, microbiological, biochemical and immunological studies. Sometimes applied with therapeutic goal for cleaning inflamed respiratory tract from excessive secretory separated purulent contents.

In veterinary practice, we use this diagnostic method for conducting a cytological analysis of the material obtained, as well as for bacteriological research. Thus, the diagnosis includes a high-quality / quantitative assessment of cells included in the bronchial mucus (for example, eosinophilic or neutrophilic inflammation prevails in a patient). Also, the resulting material is seeded to the nutrient media in order to determine which pathoger colonizes the bronchial surface and the sensitivity of the found microorganism to antibiotics is titrated.

When exactly the study is carried out

Very often at the reception to veterinary doctor Give animals with chronic cough bakelists in history (the appearance of symptoms is marked more than 1 month ago), periodically arising noisy breathing, attacks of choking and so on.

I wonder that neither x-ray chestnor clinical analysis Blood or flushing from the surface of the nasal strokes / conjunctivations cannot help differentiate asthma and bronchitis cats. Changes on the radiograph of the chest are nonspecific: as a rule, it is a similar amplification of bronchial or broncho-interstitial pattern. As for the wasches from the surface of the upper respiratory tract, it should be remembered that the microbial landscape at the level of bronchiol and mucous nasal moves is very different, and when the mycoplasma is found on the surface of the eye conjunctiva, we have no right to argue that this pathogen causes irreversible changes at the Bronchi level.

As for dogs, the diagnosis of chronic cough can also be carried out using the BALA. Thus, the cough dogs can be a symptom of very different diseases. For example, infectious and idiopathic bronchitis give the same changes in the radiography of the chest, however require completely different treatment. The method is very valuable for the treatment of therapy in the development of puppies and young dogs of heavy, refractory (sustainable) to the treatment of pneumonium antibiotics. After all, bacteriological research allows you to accurately determine which pathogen is resistant to a standard antibacterial scheme. There is also an opportunity to accurately choose the necessary and specific antibiotic.

In addition, using the method we can exclude eosinophilic infiltration syndrome, developing in young animals and requires aggressive steroid therapy to relieve attacks, while steroids assigned to the active bacterial process can destroy the patient.

How exactly is the study

For the collection of wasches from the bronchi surface, we use the bronchoscopy method. Approximately the level of the bronchial level of 2-3, the bronchoscope is introduced, which allows to investigate the surface of the bronchial tree, and also exclude possible foreign objectsInhabited to the respiratory tract, for example, with an active run. Next, using the bronchoscope, we introduce a small amount of sterile solution and very quickly take it back. The resulting material is examined under the microscope and is seeded on special environments.

Security method

Bronchoalveolar lavage is considered safe, very effective in diagnosis and often affecting therapeutic effect. Challenged the disappearance of cough for a short time after the procedure. Requires minimal anesthesia (sedation). When conducting specific training does not have side effects.

Why should this study

It is very important to understand that a chronic long progressive cough often speaks of the development of irreversible, heavy broncho-pulmonary problems, which even with competently selected therapy may not have enough to respond well to treatment. Asthma cat is characterized by a high risk of sudden fatal outcome. So a timely diagnosed diagnosis and selected therapy allow you to get rid of problems at an early stage and significantly improve the quality of life of your pet.

Veterinarian
Filimonova D.M.

With the average and severe degrees of obstructive-ventilation disorders, it is not enough to use bronchodiolitic agents and preparations that contribute to the rejection of mucous plugs, in some cases the mechanical cleansing of the bronchial tree is shown, purposeful visual lavage of the bronchi.

It is possible to wash each segmental bronchus only at bronchoscopy. Under local anesthesia, it is impracticable, and for the implementation of bronchoscopy under anesthesia, conventional IVL methods are unsuitable. We need this method of IVL, which will not only warn the further strengthening of hypoxia and hypercapnia, but also provide optimal gas exchange, despite the simultaneous execution of endobronchial interventions through the brunchoscope clearance. This ventilation method suggested Sanders (1967). It is when using this injection method that a consistent thorough washing of all segments is possible. In the case when the Karens two-piece tube is used, such conditions are not achievable, the washing is carried out blindly and uncontrollably.

The true introduction of bronchial lavage in the clinic is associated with the proposal of Thompon and Pryor (1964, 1966). To discard small and medium bronets, the TPOTRZOP in the conditions of bronchoscopy under anesthesia alternately catheterized segmental bronchi, introducing in them under a pressure of 50 ml of fluid and immediately through the same catheter sucking it. The injection of fluids made it possible to mechanically remove clots of bronchi. 800-1500 ml was required for the entire lavage, one third was able to suck back, and the rest was absorbed. Thompson used saline, sodium bicarbonate, proteolytic enzymes and detergents added to normalize the pH.

The most severe condition of the patients, according to Thompson, with co-authors (1966), does not serve as a contraindication to the bronchial lavage, since the best results were obtained in almost dying patients. Our own experience in the application of the modification of bronchial lavage fully confirms a positive assessment of such a bronchological manual. However, the routine technique of bronchoscopy, even using respiratory bronchoscopes, does not provide reliable conditions. The main disadvantage is that a multiple depressurization of the respiratory contour is needed for the integration of bronchi due to the opening of the bronchoscope viewing window. With asthma status and hypoxic coma, any pauses in IVL are unacceptable. Visit patients during asthmatic status, creating high pressure On the breath with the help of respiratory bronchoscope, difficult.

The search conducted in our clinic made it possible to elect an option fully maintaining all the advantages of the initial suggestion Tompson, but in the conditions of continuous and efficient IVL, including periods of long-term depressurization of the patient's system - bronchoscope - apparatus.

When implementing this method, the task is to avoid gas leakage through the open viewing window of the bronchoscope. The Sanders offer provided for the creation of a directional jet of oxygen in the bronchoscope tube (Fig. 11). For this, oxygen is blown through an injection needle built into the proximal part of the tube. The resistance of the thin needle is large, therefore, to create a fairly powerful jet of oxygen capable of raising intracheal pressure into several dozen centimeters of a water column, an inlet of the injection needle has to create pressure in a few atmospheres. The bronchoscope tube performs the role of diffuser. The invested gas jet not only goes in the direction of the lungs, but also carries air (injection), so during the inhalation there is not only no oxygen leakage, but, on the contrary, the atmospheric air is sucked and diluted with the breathing mixture. The flow of oxygen is periodically interrupted and then passive exhalation occurs in the atmosphere.

Fig. 11. Direction of the gasot with an injection method of artificial ventilation of the lungs during bronchoscopy: 1-supply of oxygen through an injection needle of a tubercososcopic tube; 2-climber of air from the atmosphere; 3-Tube bronchoscope; 4-voice gap; 5-trachea.

We have a special injection bronchoscope and an automatic injection respirator with a phase switching over time constructed with the engineer L. B. Taflinsky. The modified injection ventilation method used provides a mandatory measurement of intraheracual pressure, as well as a blocking, warning excessive increase in pressure, separate adjustment of the duration of inhalation and exhalation, protecting the face of the bronchologist from an exhaled air sick.

The IVL injection method is carried out "manually" by the overlapping of the feeding duct oxygen, for which the oxygen hose is shifted, or the pneumothumbler built into the hose is a switch or a special respirator.

When using this method, endoscopic manipulations practically do not affect the parameters of the IVL, and the bronchologist gets the possibility of continuous operation when the bronchoscope is constantly open. During the inhalation, intrahetic pressure can be brought to 15-40 cm water. Art., Although it is possible to obtain and higher pressure. The harder condition of the patient due to asthmatic status, the higher the pressure should be created during the breath. Frequency of breathing-10-15 in 1 min. The oxygen content in the inhaled mixture should be adjusted: at extremely the ventilation and obstruction, the ventilation is needed with pure moisturous oxygen, in other patients the oxygen content in the inhaled mixture can be reduced to 50-70% (Fig. 12).

Fig. 12. Gaza blood during bronchial lavage in the conditions of injection IVL. A - source; B - before intubation and at ventilation pure 2; In - after 5 min Ing. Ivl mask; M - after 10 min Ing. IVL; E-for 15 min Inzh. Alive; E-Osraz after the end of bronchoscopy and extbation

During the injection ventilation of PO2 arterial blood, it immediately increases significantly, and hypercaps decreases. At the time of the introduction of the bronchoscope often occurs arterial hypertensionbut during bronchoscopy awarded a trend towards normalization arterial pressureIt often disappears the earlier arrhythmia of the heart.

Bronchoscopy and lavage should be carried out under intravenous barbitura anesthesia with relaxants, sometimes additionally introduced Seduksen. If the bronchospaist component is expressed, and the preliminary inhalation of fluorotan facilitates the patient's condition, then in such patients for introductory anesthesia and to maintain it should be used by fluorotan. Extbation should be performed after the initial signs of respiratory recovery appear. For lavage bronchi enough 15-25 minutes.

Bronchi should be flushed with a warm physiological solution or a furagin-K solution in a mixture with saline. Usually consuming up to 800 ml of fluid; Approximately one third of the liquid can be sucking. In some cases, the liquid is so quickly absorbed that it is insignificant inverse.

As a rule, with washwater, a large number of fine sausage-like white clots are removed having the shape of bronchial blinds (Fig. 13). The release of fluid from the lungs sometimes continues during the first day after washing, facilitating the cough and the debit of sputum.

Fig. 13. Sleeps of bronchi, washed during endobronchial bronchoscopic lavage

To relieve asthmatic status, one, less than two washing. Patients are the greatest relief notice a few hours after the end of the intervention.

To consolidate the positive results of treatment through different times Two lava should be conducted. The use of Bronchi lavage makes it possible to reduce the doses of hormones in patients accustomed to them, and some have to abandon the use of steroids. There is also a decrease in resistance to bronchodilitics.

Currently bronchial lavage, it is the integration lava, purposeful washing of blocked small bronchi liquid under pressure, and not "rinse at random" is indispensable for the treatment of patients with severe forms bronchial asthma and asthmatic status.

Authors): S.K. Dog, P.V. Belokopytov, A.N. Lapshin, S.G. Atanasova, A.A. Ivanov
Organization (s): Innovative veterinary center of the Moscow Veterinary Academy
Magazine: №5 - 2018

UDC 619: 616.24

Keywords: bronchoalveolar lava, bronchoralol, bronchoscopy. Key Words: Bronchoalvelar Lavage, Bronchoalveoli, Bronchoscopy /

Abbreviations: Ball - Bronchoalveolar Lavai, Pav - Surfactant

The purpose of the study: describe the existing techniques for the bronchoalveolar lavage

Abst

Bronchoalveolar lavage (ball) is the minimum invasive technique used in humane and veterinary medicine for sampling from the bottom of the bottom order and alveolar spaces.

Sampling ball is used to study the congenital, cellular and humoral cell response due to the presence of cell populations that can facilitate the diagnosis of various diffuse lung diseases.

Bronchoalvelar Lavage (BAL) is a minimally Invasive Technique Utilized in Human and Veterinary Medicine to Sample The Lower Generation Bronchi and Alveolar Spaces.

Bal Sampling IS Used to Study The Congenital, Cellular and Humoral Cellular Response Due To the Presence of a Cell Population Caesed by The Presence of A Population of Cells That Can Facilitate The Diagnosis of Various Diffuse Pulmonary Diseases.

Bronchoscopy and Bal Can Provide Definitive Diagnosis In Cases of Inflammatory Airway Disease, Bronchiectasis, Eosinophilic Pneumonia, Pulmonary Parasites, Bacterial Pneumonia, Mycotic Pneumonia and Neoplasia.

The testimony for holding the ball is cough, unclear or lack of changes on the lungs radiograph, despite the manifestation of clinical signs corresponding to diseases of the respiratory tract, light-formation of lungs, pneumonia, stridor, removal of the obstruction of bronchial mucus.

Contraindications for the ball are shortness of breath (relative contraindication) and coagulopathy.

There are several criteria that guarantee the solution to the lower respiratory tract (bronchoralol): the percentage of the extracted fluid and the presence of the surfactant layer.

A higher percentage of the extracted solution (about 50%) indicates the selection of samples from the lower respiratory tract. The median of the extracted solution in dogs is 42-48%, in cats 50-75%. In turn, a small amount of extracted fluid (< 40%) говорит о том, что проба взята из крупных дыхательных путей .

Superficial substance (surfactant) is phospholipids, proteins and ionic mixture secreted by type II pneumocites in the epithelial alveolar surface to reduce the alveolar surface tension. Since the pulmonary surfactant in the respiratory tract is present only in the alveolar epithelial lumber, the presence of surfactants in the ball confirms that the sampling has been produced precisely from Alveol. In the samples of the PAV ball appears as a foam (Fig. 1).

Fig. 1. Presence of surfactant in the sample of liquid ball

Cytological analysis remains the basis for the assessment of the ball. Normally, a healthy animal in the ball contains macrophages, lymphocytes, neutrophils, eosinophils and fat cells.

Fluid samples Ball are considered unacceptable if they have been contaminated from other respiratory areas or are not a bronchoalveolar medium.

Technique of the ball

The main technique of the ball includes the infusion of a sterile isotonic solution into the lower respiratory tract and the aspiration of this solution. The ball can be carried out blindly, by conducting a catheter into lungs through an endotracheal tube, with bronchoscopic assistance or under control of x-ray. The bronchoscopic-assisted ball allows you to visualize the lower respiratory tract and direct the ball into the most affected lungs.

Ball at dogs

The disease of the lower respiratory tract in dogs leads to structural changes in bronchi (for example, thickening of the mucous membrane, increased exudation) and changes in the normal population of epithelial linging cells.

Ball in dogs is carried out under general anesthesia. Patients undergoing the ball procedure are recommended for supporting hydroatherapy during and some time after the procedure, while saturation comes to normal.

During the "blind" ball orally into the trachea through a sterile endotracheal tube, a sterile urethral catheter is introduced until it is carefully embedded in distal bronchus, feeling resistance. It is necessary to exercise caution so as not to start the catheter too far into the respiratory tract and not provoke a yathedral pneumothorax, damaging the tissue of light transbronchial. After administration from three to five times, 25 ml or 5 ml / kg (in different data) of the warm (37 C) sterile isotonic solution is immediately aspiration (transserterial washed) is immediately carried out and then 2-3 manual breaths are carried out. After that, the residue of the liquid is aspirated by gravity or using an aspirator. Sometimes the rising of the back of the animal can increase the amount of extracted fluid (Fig. 2).

Fig. 2. Raise the back of the animal body to increase the amount of recoverable fluid

This Ball method often provides lavage of caudal lung fractions (Fig. 3).

Fig. 3. A set of tools for holding ball

During the bronchoscopic ball, the bronchoscope is administered orally into the trachea. Before fulfilling the ball, a complete bronchoscopic examination is carried out. As soon as the lavage site is identified, the bronchoscope is gently inclined into subsegment bronchus. Dense fitting of the bronchoscope to the bronchi under study ensures maximum extraction of the entered solution. When a dense adjacent to bronchu is reached, a warm (37c °) isotonic solution is introduced through the biopsy channel of the bronchoscope. It is recommended to introduce a warm isotonic salt solution To reduce the risk of bronchospasm. From 1 to 4 times, a total of 5 to 50 ml of solution (1-2 ml / kg) is introduced. The studies have found that the use of volume in the calculation of ml / kg of weight leads to a greater volume of extracted fluid. The introduction of a small amount of solution may be insufficient to achieve Alveol. After the saline solution was introduced into the respiratory tract, immediate aspiration occurs with a syringe or using an aspirator, connected in series with an aspiration valve of the bronchoscope or with a urethral catheter through a sterile test tube for collecting samples. The absence of a solution with aspiration may be due to the collapse of the respiratory tract and should be imposed less effort on the syringe for aspiration. If a negative pressure It is still present, the bronchoscope can be pulled out of several millimeters, but in this case the volume of the resulting liquid may be less. It is recommended to select samples of a ball of several pieces of lungs even with diffuse lung damage. Patients with focal lung lesions (aspiration pneumonia) should be performed only from the affected lobe of the lung. If an insufficient solution volume is obtained or if there is no foam, the procedure should be repeated.

Studies of humane medicine showed that the bronchoscopic-assisted ball ensures samples of higher diagnostic quality and reliability than uncontrolled technique. But a feature and special attention, which should be used to apply this technique in veterinary medicine, in our opinion, is the complexity in the preparation of the instrumental channel to the study to eliminate the contamination of the Flora tool channel of the bronchoscope of the ball samples.

Cutting Ball

Fig. 4. Holding Ball Cat

The smaller size of the respiratory tract in cats makes bronchoscopy difficult. More complications are connected with this compared to other types of animals. For example, in a retrospective review of flexible bronchoscopy and balls in cats in the veterinary center, 38% of complications were revealed compared to 5% in humans. Most (24%) complications in this review are considered moderate (for example, the desaturation of hemoglobin). The preliminary introduction of inhalation broutine (Salbutamol, Bromide IPratropy) is recommended before the ball in cats. Cat's ball is carried out similarly to the ball in dogs. The volume of the injected solution varies up to 20 ml or 3-5 ml / kg, most often enough 2-3 administrations (Fig. 4).

Conducted studies comparing 2 aspiration methods: manual and with a suction, showed that aspiration by suction gives more aspirated liquid and better samples, but this does not affect the final results of the ball analysis.

X-ray-assisted ball

In a retrospective study, X-ray cats were carried out. An intubed patient was introduced 0.035 "Hydrophilic conductor, which introduced 8FR red rubber catheter. The ball is carried out by double administration of 5 ml of a sterile saline, which was aspirated by 20 ml syringe. As a result of the radioscopic-assisted ball, only Cranial catheterization right Share The lungs ended unsuccessfully, the catheterization of the rest of the lungs was successful, the results of cytological analysis answered all the necessary requirements. Therefore, the X-ray-assisted ball may be a practical, reliable and safe technique for sampling from all lungs, except for the cranial right lobe (Fig. 5, 6).

Fig. 5. Conducting X-ray-assisted Ball Dog

Fig. 6. Radioscopy visualization during ball

Side effects and complications after the ball

Minor complications may include bleeding, resistant hypoxemia, bronchospasm and a viszal fainting. Major complications include pneumonia, arrhythmias, pneumothorax, pneumomediastinum, respiratory failure and heart stop.

All patients after the ball require additional oxygenation. If cyanosis or reduction of saturation is noted, additional oxygenation is necessary. If the patient is not enough additional oxygenation, other reasons should be considered, such as bronchospasm or pneumothorax. Also, after any lavage procedure, there may be a temporary deterioration in the respiratory function or cough.

Reports about cases of spontaneous pneumothorax. Rarely, but complications after the ball may be fatal, such patients either had a respiratory distress syndrome before the ball, or it was impossible to restore adequate oxygenation and ventilation after the procedure.

A 2% mortality rate / euthanasia is reported (2/101). In this study, mortality is related to the preceding procedure Ball with respiratory distress syndrome. These finds lead to the conclusion that the preceding shortness of breath is a relative contraindication to the ball. Also reported significantly bronchospasm after the ball in dogs with eosinophilic diseases of the respiratory tract, which was stopped using bronchodulators and oxygenation. In a retrospective review of flexible bronchoscopy, cats, cats reported that 6% of cats needed night hospitalization and oxygen-treatment, 3% developed pneumothorax and 6% mortality or euthanasia were associated with the inability to restore ventilation after the procedure. Significantly less complications in cats are recorded, which previously obtained terbutal 0.01 mg / kg p / k for 12-24 hours. Before carrying out bronchoscopy and ball (8%) compared to cats, which pre-not received (40%). Preliminary receipt of inhalation broutine (Salbutamol, IPratropy Bromide) before the ball warns bronchokonstriction in allergen-sensitive cats. Thus, the preliminary receipt of bronchoscopy in cats is currently recommended.

Ball fluid analysis

To achieve the best results, the treatment of samples ball must be performed within an hour after harvesting. When evaluating cytology, it is necessary to estimate the lavage samples from each share separately. In one of the studies, 37% of dogs had different results when samples from different pulmonary fractions were evaluated.

In each sample, it is necessary to calculate at least 200 cells. The most common type of cells dedicated to the ball is the alveolar macrophage. Cat Ball Normal liquid contains a greater amount of eosinophils compared with other species.

Most dogs S. bacterial infections Have neutrophilic inflammation. In dogs S. chronic bronchitis Most often, mixed inflammatory or neutrophilic inflammation is observed. An increase in the number of eosinophils (from 20% to 450%) is observed in dogs with eosinophilic bronchopneumonia. Also, mixed inflammation is often found in the presence of fungal infections.

Neutrophilic inflammation with the presence or without intracellular bacteria can be observed in cats with pneumonia. Cats with bronchitis or asthma often have increased content eosinophils. However, neutrophilic and eosinophilic inflammations are not pathognomonic for an infectious or immunological process, since both eosinophilic and neutrophilic inflammation can also be observed in neoplasia.

It is enough difficult to diagnose neoplasia from the samples obtained with the ball. All cells must be investigated by malignancy criteria. In a small study of the cat with histologically diagnosed carcinoma, neutrophilic inflammation was shown, but no signs of cancer were found in the cytology of the liquid obtained with the ball. Another study showed a significant coincidence of the number of differential cells in cats with pneumonia, bronchitis and neoplasia. For these reasons, the calculation of the ball cells should be interpreted in combination with clinical signs and radiography data and bronchoscopy.

Normally, the respiratory tract is not sterile, as a result of which quantitative calculation bacterial cells It can help differentiate contamination from real respiratory infections. The content of more than 1.7 * 10 3 colony-forming units per milliliter is characteristic of the presence of bacterial bronchopneumonia. In all the obtained samples, it is necessary to analyze the presence of aerobes and mycoplasmas. Analysis for the presence of fungi should be carried out in endemic areas.

Reports to the use of PCR in the diagnosis of species Micoplasma, Bordetella Bronchiseptica and TOXOPLASMA GONDII.. The PCR results must be interpreted with caution due to the fact that Mycoplasma and Bartonella can be present in the Rotohlotka in dogs and cats. Consequently, positive results do not guarantee that pathogens data cause current clinical signs in a patient. In addition, the negative result does not exclude the presence of an infection. Despite the fact that the microorganism may be present in the respiratory tract, it may not be represented in a small sample used to extract DNA, as a result, getting a falsely negative result.

Table 1.

Cytology after the ball

.

Fig. 7. Segmented neutrophils and alveolar rice. 8. Cereal respiratory epithelium

Macrophages on the background of mucus

Fig. 9. segmented neutrophils on the background of rice. 10. Conglomerate cells of the epithelium

eosinophilic

Pink intermediate substance - mucus

conclusions

The diagnostic value of this procedure should not be overvalued, because patients with respiratory diseases have increased risks associated with anesthesia and respiratory procedures. The risk of procedure should always be assessed from the point of view of the expected results. Also, as studies show, the ball with bronchoscopy is accompanied by a smaller amount of complications and a large diagnostic value of the obtained samples. The choice of techniques can also be made on the basis of a material base of the veterinary institution, but in any case the fulfillment of the ball must be regulated technically and executed by trained specialists.

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Diagnostic capabilities of bronchoalveolar lavage

M.V. Samsonov

The introduction into the clinical practice of fibrobronchoscopy and the techniques of the bronchoalveolar lavage (ball), which allows to obtain bronchial washes (BS) and bronchoalveolar washes (bass), significantly expanded the diagnostic capabilities in pulmonology. Thanks to the method of Ball possible application A whole range of cytological, bacteriological, immunological, biochemical and biophysical methods. These studies contribute to the correct diagnosis of oncological diseases and disseminated processes in the lungs, and also allow the activity of the inflammatory process in the bronchoalveolar space.

Method Ball

Ball is carried out at fibrombronho-creation under local or general anesthesia. The bronchoscope is introduced in the equity bronchus (usually the average share of the right lung), the bronchial tree is washed with a large amount of physiological solution heated to 37 ° C. After washing, the solution is completely aspirated from the bronchial tree.

The bronchoscope is introduced at the mouth of segmental bronchus, occlusive it. A polyethylene catheter is carried out through the biopsy channel of the bronchoscope and, through it, 50 ml of physiological solution is introduced into the lumen of segmentar bronchi, which is then fully aspiring. The resulting portion of the liquid is a bronchial washing. Then the catheter is promoted by 6-7 cm deep into segmentation

Maria Viktorovna Samsonova -

dokt. honey. Sciences, head. Lab. pathological anatomy Roszdrava Pulmonology Research Institute.

bronchine and fractionally introduce 4 servings of 50 ml of physiological solution, which every time fully aspi-ride. These combined portions and constitute a bronchoalveolar wash.

BS and BAS research methods

The main methods of the BS and BAS research include biochemical and immunological examination of the supernatant, as well as the study of cellulates. At the same time, the viability of the BS cells and bass, cytogram, is calculated, conduct cytochemical studies of cells, as well as a Qi-Tobacterioscopic assessment. Recently, a methodology for calculating the macrophage formula of the bass has been developed various diseases bronchopulmonary system. The exploration ball also allows you to estimate the state of the surfactant lung system by measuring the surface tension and the study of the phospho lipid composition of the surfactant.

The bronchial portion of the ball is used to conduct high-quality and quantitative microbiological studies. In addition, according to changes in the cellular composition of the BS, it is possible to determine the severity of the inflammatory response in the bronchial tree.

bronchial epithelium 5-20%

including

cylindrical epithelium 4-15% Flat epithelium 1-5%

alveolar macrophages 64-88% neutrophils 5-11%

lymphocytes 2-4%

furium cells 0-0.5%

eosinophils 0-0.5%

The normal cytogram of the alveolar portion of the ball (Fig. 1) is given in Table. one.

Diagnostic value of the BS and BAS study

The greatest diagnostic value of the BS and bass study is to evaluate the degree of inflammation in the tracheoobronchial tree, with tumors of the lung and alveolar pro-theyony.

The cytological study of the bass has a high diagnostic value only in some diseases of the lungs. Such nosologies includes histiocytosis, in which Langer-Hans cells appear (in their cytoplasm, with electron microscopy, characteristic X-calves are determined, it is an EC1 +-cells in the immunophenotype). With the help of bass it is possible to confirm the presence of pulmonary bleeding. The bass study is also shown in the verification of the alveolar proteino, for which the presence of an extracellular substance is characterized (Fig. 2), well-defined with a light (chic reaction) and electron microscopy. With this disease, the ball serves not only the diagnostic, but also therapeutic procedure.

Fig. 1. Normal cell composition bass. Coloring on Romanovsky. x400.

With pneumoconiosis using the BAS study, it is possible to only confirm the exposition to the dust agent. Specific diagnosis of berylliosis can be carried out in the study of the functional proliferative activity of the BAS cells in response to the effect of beryllium salts. When asbestos, the bass can detect asbestos tales (Fig. 3) in the form of characteristic fibers - both outside-cell and intracellularly. These calves are asbestos fibers with aggregated ge-mosseiderine, ferritin, glycoprotein, so they are well stained when carrying out a chic reaction and painting by perls. Extremely rare asbestos tales are found in persons who had non-professional contact with asbestos, while the concentration of such particles in the bass does not exceed 0.5 per 1 ml. The bass may also detect pseudo-scale tales - with pneumoconosis associated with the effects of coal dust, aluminum, fiberglass, etc.

In patients with immunodeficiency states (in particular, HIV infection), the ball is a method of choice for detecting pathogens of infectious lung lesions. The sensitivity of the ball in the diagnosis of a pneumatic infection (Fig. 4), according to some data, exceeds 95%.

With other diseases, the research bass is not highly specific, but can give additional informationwhich is estimated in a complex with clinical, radiological, functional and laboratory data.

With diffuse alveolar bleeding (DAC), which occurs during various diseases, free and phagocyted erythrocytes and Si derorofagi can be detected in the bass (Fig. 5). Bass serves effective method Detection of duck even in the absence of hemoptalia when the diagnosis of this state is extremely complex. Duck should be differentiated with sharp respiratory distress syndrome (ORDS),

in which Siderophages also appear in the bass.

Within differential diagnosis Idiopathic Fib-Rosising Alveo-Lita (IFA) Cytological Study BAS allows you to exclude other interstitial lung diseases. Thus, a moderate increase in the share of neutrophils and eosino-philips in the bass does not contradict the diagnosis of ELISA. A significant increase in the percentage of lymphocytes and eosinophils is uncharacteristic for IFA, and in these cases should be thought about other alleo-litas (exogenous allergic, medicinal or professional).

The cytological study of the bass serves as a sensitive method in the diagnosis of exogenous allergic allergic allergic (EAA). The high percentage of lymphocytes, the presence of plasma and fat cells, as well as "dust" macrophages, in combination with anamnestic and laboratory data, allows diagnosing EAA. May appear in the Bass Eosi

Table 1. Normal bass cytogram

Cellular composition bass non-smoking smokers

Citosis, cell number x106 / ml 0.1-0.3\u003e 0.3

Alveolar macrophages,% 82-98 94

Lymphocytes,% 7-12 5

Neutrophils,% 1-2 0.8

Eosinophils,%<1 0,6

Fat cages,%<1 <1

Fig. 2. Extracellular substance in bass with alveolar proteinosis. Coloring on Romanovsky. x400.

nophyls or giant multi-core cells (Fig. 6). Among lymphocytes predominate cells with immunophenotype C03 + / C08 + / C057 + / C016-. It should be remembered that a few months later, along with T-suppressors, the number of T-helpers begins to increase. Additional research methods make it possible to exclude other diseases in which there is an increase in the share of lymphocytes in the bass - diffuse diseases of the connective tissue, drugs of the bronchiolite with organic pneumonia (OUTS), silicos.

In sarcoidosis, an increase in the share of lymphocytes in the bass is also noted, and for sarcoidosis, it is characterized by

Fig. 4. Pneumocystis jiroveci in bass. Coloring on Romanovsky. x400.

Fig. 5. Siderophages in the bass. Pearl coloring. x100.

www.atmosphere-ph.ru.

Fig. 6. EAA: Raising the share of eosi-nophyls, neutrophils, lymphocytes in bass, giant multi-core cell. Coloring on Romanovsky. x200.

Fig. 7. "Amiodronic Light" (LA): macrophages with foamy cytoplasma in the bass. Coloring on Romanovsky. x1000, oil immersion.

Fig. 8. Lymphocytic type of the BAS cytogram. Coloring on Romanovsky. x1000, oil immersion.

the ratio of T-helpers and T-suppress-ditch (C04 + / CE8 +) above 3.5 (the sensitivity of this feature is 55-95%, specificity - up to 88%). In bass in patients with sarcoidosis, giant multi-core cells (like a foreign body cells) may also be discovered.

Fig. 9. Neutrophil Type of BAS cytogram. Coloring on Romanovsky. x1000, oil immersion.

With medicinal alveoli

morphological changes in lungs can be diverse, often observed alveolar hemorrhagic syndrome or bloody. In the cytogram bass, an increase in the share of eosinophils, neut-ralophiles may be noted, but most often with La opi

Table 2. Examples of the use of cytological analysis bass for differential diagnostics (according to Ogep M. E1 A1., 2000)

Cytogram Indicators

Bass and their assessment

Clinical examples of a cytogram bass

Cytosis, x104 / ml 29 110 100 20 64

Macrophages,% 65.8 18.2 19.6 65.7 41.0

Lymphocytes,% 33.2 61.6 51.0 14.8 12.2

Neutrophils,% 0.6 12.8 22.2 12.4 4.2

Eosinophils,% 0.2 6.2 7.0 6.8 42.2

Puffy cells,% 0.2 1,0 0.2 0.3 0.4

Plasmocytes,% 0 0.2 0 0 0

CO4 + / CO8 + 3.6 1.8 1.9 2.8 0.8

Bacterial sowing - - - - - -

Most likely diagnosis of sarcoidosis EAA LA IFA OEP

The probability of the correctness of the diagnosis *,% 99.9 99.6 98.1 94.3 was not calculated

* Calculated with the help of a mathematical model. Designations: OEP - acute eosinophilic pneumonia.

the increase in the percentage of lymphocytes is opened, among which, as a rule, the E8 +-cells are dominated. A very high content of neutrophils in the bass occurs when taking antidepressant nomiphenenzine (the proportion of neutrophy-fishing can reach 80%, followed by its decrease and simultaneous increase in the number of lymphocytes). With amiodonic LA ("amiodarone light"), specific changes in the bass occur in the form of a large number of "foam" macrophages (Fig. 7). This is a very sensitive, but a small sign: the same macrophages can also be detected with other diseases (EAA, OBO), as well as in the receiving amiodaries of patients in the absence of alveolitis (amiodarone increases the content of phospholipids, especially in phagocytes).

In other cases, when the ball does not reveal highly specific features of any disease, this method allows you to limit the differential-diagnostic search (Table 2 and 3) by the framework of a certain group of nosological units with one type or another al-Volyol type:

Lymphocytic (increase in the share of lymphocytes, fig. 8): sarcoidosis, hypersensitive pneumonitis, affectation pneumonia, ELISA, chronic infectious process in lungs, AIDS, silicosis, SHEGREEN syndrome, Crohn's disease, carcroids, medicinal pneumopathy;

Neutrophilic (increase in the proportion of neutrophils, Fig. 9): sclerodermia, dermatomyositis, acute infectious process in the lungs, SAR-COIDOZ with malignant current, asbestosis, drug al-wonder;

Eosinophilic (increase in the share of eosinophils, Fig. 10): Angiite Cry-Ja-Strauss, eosinophilic pneumonia, medicinal alveolit;

Mixed (Fig. 11): tuberculosis. Gisticiocytosis.

When diagnosing a lighter cancer, the ball method has an advantage

Table 3. Bass cytological indicators are normal and changed of their various pathologies (according to Ogep M. E1 A!, 2000)

Alveolar macrophages lymphocytes neutrofils eosinic films plasma-quotes Fat cells CD4 + / CD8 + ratio

Normal values

Non-smokers 9.5-10.5 * 0.7-1.5 * 0.05-0.25 * 0.02-0.08 * 0 * 0,01-0.02 * 2.2-2.8

85-95% 7,5-12,5% 1,0-2,0% 0,2-0,5% 0% 0,02-0,09%

Smokers 25-42 * 0.8-1.8 * 0.25-0.95 * 0,10-0.35 * 0 * 0,10-0.35 * 0.7-1.8

90-95% 3,5-7,5% 1,0-2,5% 0,3-0,8% 0% 0,02-1,0%

Nonapphetz ionic mist

Sarcoidosis T \u003d \u003d / t - \u003d / t t / \u003d / 4

EAA "Fenisted" MF TT T \u003d / t +/- TTT 4 / \u003d

Drug "Fencing" MF TT T T T +/- TT 4 / \u003d

alveolit

IFA T T T / TT T - T \u003d

Oops "Fenisted" MF T T T T - / + \u003d / T 4

Eosinophilic T \u003d TT +/- \u003d / t 4

pneumonia

Alveolar "foam" MF T \u003d \u003d - N.D. T / \u003d.

proteinosis

Diseases connect \u003d / t \u003d / t - \u003d / t t / \u003d / 4

tanted fabric

Pneumoconiosis WVV (particles) T t \u003d / t - \u003d / t t / \u003d / 4

Diffuse alveoy-color \u003d / t t \u003d / t - nd. \u003d.

large bleeding on Fe: +++

Ords coloring on Fe: + T TT T - \u003d / T 4 / \u003d

Malignant tumors

Adenocarcinoma \u003d \u003d \u003d - \u003d \u003d

Cancer lymphangitis t t t / \u003d t / \u003d - / + t / \u003d 4 / \u003d

Hemoblastosis t t t - / + t 4 / \u003d

And non-adhesions

Bacterial WVV (bacteria) \u003d TT T - N.D. \u003d.

Viral VVV T T T T - N.D. T / \u003d.

Tuberculosis WVV (mycobacterium) T \u003d T - T \u003d

HIV VVT T t t t / \u003d - n.d. four

Designations: MF - macrophages, WPV - intracellular inclusions; Indicator: T - elevated; TT - significantly increased; 4 -Pongen; \u003d / T - not changed, less often increased; T / \u003d / 4 - can be increased, lowered or not changed; T / tt - elevated, less frequently increased significantly; T / \u003d - increased, less frequently changed; 4 / \u003d - lowered, less frequently changed; \u003d - not changed; - not; - / + - are rarely found; +/- meet; N.D. - there is no data.

* The data is presented in absolute H104ml-1 numbers.

before studying the sputum in relation to the detection of tumor cells, since the material may be

raped from the share or segment where the tumor is localized. Ball makes it possible with a greater probability

diagnose peripheral tumors, including bronchio-salted cancer (Fig. 12).

Fig. 10. Eosinophilic type of cytogram bass, shark-co-leiden crystals. Coloring on Romanovsky. x200.

Fig. 11. Mixed type of cytogram bass: increase in the share of lymphocytes, neutrophils, eosinophi. Coloring on Romanovsky. x1000, oil immersion.

Fig. 13. BAS with chronic bronchitis: the presence of cylindrical seating cells, neutrophils, cluster of cokkkki flora. Coloring on Romanovsky. x1000, oil immersion.

Fig. 14. Mycobacteria tuberculosis in the bass. Coloring in Civil-Nill-Sen. x1000, oil immersion.

Fig. 15. Candida Albicans mushroom pseudomynecia in bass. Coloring on Romanovsky. x200.

The cytobacteroscopic method allows you to reveal and semi-graciously estimate the content of bacteria in bass (Fig. 13), mycobacteria (Fig. 14) and mushrooms (Fig. 15). These results (bacteria can be differentiated by gram) serve as the basis for the appointment of relevant antibacterial therapy until the results of bacteriological research are obtained. In casuistry

Fig. 16. A significant increase in the number of neutrophils in the bass, numerous simple-type AmeB types. Coloring on Romanovsky. x200.

The BAS study allows us to estimate the degree of activity of the inflammatory process in infectious diseases and the effectiveness of the therapy. The low degree of inflammation activity is characterized by an increase in the bass share of neutrophils in the range of 10%,

average - up to 11-30%, high - more than 30%.

The use of histochemical methods for studying the ball cells is possible with their high vitality (more than 80%).

Conclusion

When evaluating the changes identified in the BS and the bass, it is necessary to follow certain rules and remember the following:

The identified changes are characteristic only for the segment under study, therefore it should be treated carefully if the process is not diffuse;

The identified changes are characteristic of this point in time;

Since the lungs are experiencing the impact of simultaneously many factors (smoking, pollutants, etc.), it is necessary to always exclude the possibility of the influence of these factors on the development of pulmonary pathology.

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Books publishing house "Atmosphea

Amelina E.L. et al. Milkoactive therapy /

Ed. A.G. Chuchalin, A.S. Belevsky

The monograph summarizes modern ideas about the structure and functioning of mukiciliary clearance, its disorders in various diseases of the respiratory organs, research methods; The main drugs and irritable methods for the correction of mukiciliary clearance with bronchopulmonary pathology are considered. 128 p., Il.

For doctors of a wide profile, therapists, pulmonologists, students of medical universities.