CHEST Guidelines-POINT--Should-BAL-Be-Routinely-Performed-in-the-Di (1)

POINT--Should-BAL-Be-Routinely-Performed-in-the-Di (1)

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In the editorial titled "Should BAL Be Routinely Performed in the Diagnostic Evaluation of Idiopathic Pulmonary Fibrosis? Yes" by Athol U. Wells and Maria A. Kokosi, the authors argue for the routine use of bronchoalveolar lavage (BAL) in diagnosing idiopathic pulmonary fibrosis (IPF). They claim that while high-quality evidence is often lacking in diagnostic tests for interstitial lung diseases (ILD), BAL is essential due to its capability to exclude other conditions that mimic IPF, such as hypersensitivity pneumonitis (HP) and nonspecific interstitial pneumonia (NSIP).<br /><br />Despite BAL’s nonspecific nature with neutrophil levels, its diagnostic value lies in lymphocyte count discrepancies that distinguish IPF from diseases like HP and NSIP. The difficulty lies in its low sensitivity levels, but the authors argue that its exclusion capability holds significant value, especially when connected with other diagnostic methods like surgical lung biopsy (SLB).<br /><br />The authors contend that BAL's role is crucial in surgical biopsy decisions, balancing biopsy risks with diagnostic clarity, even though the 2011 IPF guidelines recommended routine biopsies for all suspected IPF cases without classic UIP appearance, which they acknowledge as flawed. They emphasize that ancillary information from BAL is vital in stratifying which patients should undergo biopsy, particularly given potential procedural risks.<br /><br />Furthermore, Wells and Kokosi acknowledge the current 'low-quality' evidence status for BAL due to the absence of expansive, modern studies, yet they stress its practical value based on substantial historical findings. They conclude that emerging technologies, like biomarker quantification and transbronchial lung cryobiopsy, could potentially amplify BAL's diagnostic utility, warranting its continued routine use in the evaluation of suspected IPF cases.

Keywords

bronchoalveolar lavage

idiopathic pulmonary fibrosis

diagnostic evaluation

interstitial lung diseases

hypersensitivity pneumonitis

nonspecific interstitial pneumonia

surgical lung biopsy

biomarker quantification

transbronchial lung cryobiopsy

diagnostic utility