Bronchoscopy

Indications

Diagnostic

  • Diagnosis of Endobronchial Airway Lesion (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
  • Diagnosis of Hilar/Mediastinal Lymphadenopathy
    • Endobronchial Ultrasound-Transbronchial Needle Aspiration (EBUS-TBNA)
  • Diagnosis of Source of Hemoptysis (see Hemoptysis, [[Hemoptysis]])
  • Diagnosis of Vocal Cord Abnormality (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
  • xxxx
  • xxxx
  • xxxx
  • xxxx

Therapeutic

  • Hemoptysis (see Hemoptysis, [[Hemoptysis]])
  • xxxx
  • xxxx
  • xxxx

Technique

  • Requires Procedural Sedation (see Sedation, [[Sedation]])

Bronchoalveolar Lavage (BAL)

Normal Bronchoalveolar Lavage (BAL) Cellular Patterns (Non-Smokers) (Am J Respir Crit Care Med, 2012) [MEDLINE]

  • Alveolar Macrophages: >85%
  • Lymphocytes: 10-15%
    • CD4/CD8 Ratio: 0.9-2.5
  • Neutrophils: ≤3%
  • Eosinophils: ≤1%
  • Squamous Epithelial/Ciliated Columnar Epithelial Cells: ≤5%
    • Presence of Squamous Epithelial Cells Indicates Upper Airway Secretion Contamination: epithelial cells >5% indicates that sample is suboptimal (BAL cellular pattern should be interpreted with caution)

Need for Bronchoalveolar Lavage (BAL) Cellular Analysis Based on Appearance of HRCT (Am J Respir Crit Care Med, 2012) [MEDLINE]

  • HRCT with Extensive Honeycombing: BAL cellular analysis is not required
  • HRCT with Diagnostic Pattern: BAL cellular analysis is not required
  • HRCT with Non-Diagnostic Pattern: BAL cellular analysis is recommended

Etiology of Bronchoalveolar Lavage (BAL) Lymphocytosis (>15%) (Am J Respir Crit Care Med, 2012) [MEDLINE]

bal-lymphocytosis

BAL Lymphocytosis >15%

  • Collagen Vascular Disease
  • Cryptogenic Organizing Pneumonia (COP) (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
  • Drug-induced Pneumonitis
  • Granulomatous Lung Disease
    • Chronic Berylliosis (see Beryllium, [[Beryllium]])
    • Hypersensitivity Pneumonitis (HP) (see Hypersensitivity Pneumonitis, [[Hypersensitivity Pneumonitis]])
      • Low CD4/CD8 Ratio Occurs Due to a Relative Increase in CD8 Cells
      • Differential with >50% Lymphocytes + >3% Neutrophils + >1% Mast Cells is Suggestive of Acute Hypersensitivity Pneumonitis
    • Sarcoidosis (see Sarcoidosis, [[Sarcoidosis]]): lymphocytosis >35% may be seen
      • High CD4/CD8 Ratio >3.5: CD41/CD81 >4 is highly specific for sarcoidosis in the absence of an increased proportion of other inflammatory cell types
  • Lymphocytic Interstitial Pneumonitis (LIP) (see Lymphocytic Interstitial Pneumonia, [[Lymphocytic Interstitial Pneumonia]])
  • Lymphoproliferative Disorder
  • Nonspecific Interstitial Pneumonia (NSIP) (see Nonspecific Interstitial Pneumonia, [[Nonspecific Interstitial Pneumonia]])
  • Radiation Pneumonitis (see Radiation Pneumonitis and Fibrosis, [[Radiation Pneumonitis and Fibrosis]])
  • Tuberculosis (see Tuberculosis, [[Tuberculosis]])

BAL Lymphocytosis ≥25%

  • Cryptogenic Organizing Pneumonia (COP) (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
  • Drug-Induced Pneumonitis
  • Granulomatous Lung Disease
    • Chronic Berylliosis (see Beryllium, [[Beryllium]])
    • Hypersensitivity Pneumonitis (HP) (see Hypersensitivity Pneumonitis, [[Hypersensitivity Pneumonitis]])
      • Low CD4/CD8 Ratio Occurs Due to a Relative Increase in CD8 Cells
      • Differential with >50% Lymphocytes + >3% Neutrophils + >1% Mast Cells is Suggestive of Acute Hypersensitivity Pneumonitis
    • Sarcoidosis (see Sarcoidosis, [[Sarcoidosis]]): lymphocytosis >35% may be seen
      • High CD4/CD8 Ratio >3.5: CD41/CD81 >4 is highly specific for sarcoidosis in the absence of an increased proportion of other inflammatory cell types
  • Lymphocytic Interstitial Pneumonia (LIP) (see Lymphocytic Interstitial Pneumonia, [[Lymphocytic Interstitial Pneumonia]])
  • Lymphoproliferative Disorder
  • Nonspecific Interstitial Pneumonia (NSIP) (see Nonspecific Interstitial Pneumonia, [[Nonspecific Interstitial Pneumonia]])

BAL Lymphocytosis >50%

  • Nonspecific Interstitial Pneumonia (NSIP) (see Nonspecific Interstitial Pneumonia, [[Nonspecific Interstitial Pneumonia]])
  • Hypersensitivity Pneumonitis (HP) (see Hypersensitivity Pneumonitis, [[Hypersensitivity Pneumonitis]])
    • Low CD4/CD8 Ratio Occurs Due to a Relative Increase in CD8 Cells
    • Differential with >50% Lymphocytes + >3% Neutrophils + >1% Mast Cells is Suggestive of Acute Hypersensitivity Pneumonitis

Etiology of Bronchoalveolar Lavage (BAL) Neutrophilia (>3%) (Am J Respir Crit Care Med, 2012) [MEDLINE]

  • Acute Bronchitis (see Acute Bronchitis, [[Acute Bronchitis]])
  • Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, [[Acute Respiratory Distress Syndrome]]): BAL neutrophilia may be >50%
  • Asbestosis (see Asbestos, [[Asbestos]])
  • Aspiration Pneumonia (see Aspiration Pneumonia, [[Aspiration Pneumonia]]): BAL neutrophilia may be >50%
  • Collagen Vascular Disease
  • Diffuse Alveolar Damage (DAD)
  • Hypersensitivity Pneumonitis (HP) (see Hypersensitivity Pneumonitis, [[Hypersensitivity Pneumonitis]])
    • Low CD4/CD8 Ratio Occurs Due to a Relative Increase in CD8 Cells
    • Differential with >50% Lymphocytes + >3% Neutrophils + >1% Mast Cells is Suggestive of Acute Hypersensitivity Pneumonitis
  • Idiopathic Pulmonary Fibrosis (IPF) (see Idiopathic Pulmonary Fibrosis, [[Idiopathic Pulmonary Fibrosis]])
  • Infection: BAL neutrophilia may be >50%
    • Bacterial Pneumonia
    • Fungal Pneumonia

Etiology of Bronchoalveolar Lavage (BAL) Eosinophilia (>1%) (Am J Respir Crit Care Med, 2012) [MEDLINE]

General Comments

  • Although Pathologic Examination of the Lung is the Gold Standard for Diagnosing Eosinophilic Pneumonia, BAL is a Widely-Accepted Noninvasive Surrogate of Lung Biopsy for Diagnosis in Patients with High-Resolution Features of Eosinophilic Pneumonia
    • However, No Study Has Definitely Established a Correlation Between the Presence of BAL Eosinophilia and the Finding of Eosinophilic Pneumonia on Lung Pathology
  • BAL Eosinophil Percentage in Various Disease States
    • Normal: BAL eosinophil <1%
    • BAL Eosinophilia 3-40% (and Especially Between 3-9%): may be found in various disorders
    • BAL Eosinophilia >40%: found predominantly in patients with chronic eosinophilic pneumonia
  • BAL Eosinophil Percentage Proposed Cut-Off Values
    • Diagnosis of Idiopathic Acute Eosinophilic Pneumonia: BAL Eosinophilia >25%
    • Diagnosis of Idiopathic Chronic Eosinophilic Pneumonia: BAL Eosinophilia >40%

Eosinophilic Pulmonary Syndromes of Known Etiology

Parasitic Infection
  • General Comments: parasite-associated eosinophilic pneumonias represent the most common etiologies of pulmonary infiltrates with eosinophilia worldwide
  • Capillaria Aerophila (see Capillariasis, [[Capillariasis]])
    • Epidemiology: rare etiology of eosinophilic pulmonary infiltrates
  • Clonorchis Sinensis (see Clonorchiasis, [[Clonorchiasis]])
    • Epidemiology: rare etiology of eosinophilic pulmonary infiltrates
  • Dirofilariasis (see Dirofilariasis, [[Dirofilariasis]])
    • Clinical: eosinophilic pulmonary infiltrates
  • Echinococcosis (see Echinococcosis, [[Echinococcosis]])
  • Paragonimiasis (see Paragonimiasis, [[Paragonimiasis]])
    • Epidemiology: rare etiology of eosinophilic pulmonary infiltrates
  • Schistosomiasis (see Schistosomiasis, [[Schistosomiasis]]): the manifestations of schistosomiasis in the lung vary dependent on the stage of disease
    • Early Acute Schistosomiasis: transient, multiple small pulmonary nodules with peripheral eosinophilia
    • Chronic Schistosomiasis: embolization of ova in small arteries of the lung results in granuloma formation, occlusion and remodeling of pulmonary arteries, and further pulmonary hypertension mediared by portopulmonary hypertension
    • Post-Treatment of Schistosomiasis: eosinophilic pneumonitis (lung shift, verminous pneumonia, reactionary Loffler-like pneumonitis) due to antigen release following treatment
  • Simple Pulmonary Eosinophilia (Loffler Syndrome) (see Simple Pulmonary Eosinophilia, [[Simple Pulmonary Eosinophilia]])
    • Ascaris Lumbricoides (or Ascaris Suum): most common etiology of simple pulmonary eosinophilia (Loffler syndrome)
    • Necator Americanus
    • Ancylostoma Duodenale
    • Ancylostoma Brazliense or Canium
    • Entamoeba Histolytica
    • Fasciola Hepatica
    • Schistosomiasis (see Schistosomiasis, [[Schistosomiasis]]): the manifestations of schistosomiasis in the lung vary dependent on the stage of disease
      • Early Acute Schistosomiasis: transient, multiple small pulmonary nodules with peripheral eosinophilia
      • Chronic Schistosomiasis: embolization of ova in small arteries of the lung results in granuloma formation, occlusion and remodeling of pulmonary arteries, and further pulmonary hypertension mediared by portopulmonary hypertension
      • Post-Treatment of Schistosomiasis: eosinophilic pneumonitis (lung shift, verminous pneumonia, reactionary Loffler-like pneumonitis) due to antigen release following treatment
    • Strongyloides Stercoralis: simple pulmonary eosinophilia (Loffler syndrome) may occur when larvae migrate through the lungs after acute infection
  • Strongyloides Stercoralis Hyperinfection Syndrome (see Strongyloides Stercoralis, [[Strongyloides Stercoralis]])
    • Epidemiology: occurs in 20% of patients hospitalized with strongyloidiasis and coexisting chronic lung disease (COPD, asthma)
    • Diagnosis: rhabditiform larvae may be recovered via bronchoalveolar lavage, bronchial wash, or sputum sample
    • Clinical: cough/wheezing/dyspnea with bilateral patchy infiltrates and variable degree of eosinophilia
  • Trichinosis (see Trichinosis, [[Trichinosis]])
    • Epidemiology: rare etiology of eosinophilic pulmonary infiltrates
  • Tropical Pulmonary Eosinophilia (Occult Filariasis) (see Tropical Pulmonary Eosinophilia, [[Tropical Pulmonary Eosinophilia (Occult Filariasis)]])
    • Wuchereria Bancrofti
    • Brugia Malayi
    • Brugia Timori
  • Visceral Larva Migrans (see Visceral Larva Migrans, [[Visceral Larva Migrans]])
    • Toxocara Canis
Other Infection
  • Aspergillus Niger (see Aspergillus, [[Aspergillus]])
    • Epidemiology: case reports of eosinophilic pneumonia
  • Bipolaris Australiensis
    • Epidemiology: case reports of eosinophilic pneumonia
  • Bipolaris Spicera
    • Epidemiology: case reports of eosinophilic pneumonia
  • Brucellosis (see Brucellosis, [[Brucellosis]])
    • Epidemiology: case reports of eosinophilic pneumonia [Eosinophilia and pneumonitis in chronic brucellosis: a report of two cases. Ann Intern Med. 1942;16:995-1001]
  • Coccidioidomycosis (see Coccidioidomycosis, [[Coccidioidomycosis]])
    • Clinical: pronounced peripheral eosinophilia may be an early indicator of dissemination
  • Cryptococcosis (see Cryptococcosis, [[Cryptococcosis]])
    • Epidemiology: case reports of eosinophilic pneumonia (South Med J, 1995) [MEDLINE]
  • Histoplasmosis (see Histoplasmosis, [[Histoplasmosis]])
  • Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]])
  • Influenza Virus (see Influenza Virus, [[Influenza Virus]])
    • Epidemiology: may produce eosinophilic pneumonia in some cases
  • Mycobacterium Simiae (see Mycobacterium Simiae, [[Mycobacterium Simiae]])
    • Epidemiology: case reports of eosinophilic pneumonia (NEJM, 1989) [MEDLINE]
  • Pneumocystis Jirovecii (see Pneumocystis Jirovecii, [[Pneumocystis Jirovecii]])
    • Epidemiology: BAL eosinophilia has been reported in HIV-associated cases
  • Respiratory Syncytial Virus (RSV) (see Respiratory Syncytial Virus, [[Respiratory Syncytial Virus]])
    • Epidemiology: may produce eosinophilic pneumonia in some cases
  • Tuberculosis (see Tuberculosis, [[Tuberculosis]])
    • Epidemiology: may produce eosinophilic pneumonia in some cases
Allergic Bronchopulmonary Aspergillosis and Related Syndromes
Drug-Induced Pulmonary Eosinophilia (see Drug-Induced Pulmonary Eosinophilia, [[Drug-Induced Pulmonary Eosinophilia]])
  • More Than 80 Drugs/Toxins Have Been Reported to Cause Drug-Induced Pulmonary Eosinophilia
Other
  • Breast Radiation-Associated Eosinophilic Pneumonia (see Radiation Therapy, [[Radiation Therapy]])
    • Clinical: chronic eosinophilic pneumonia
  • Eosinophilia-Myalgia Syndrome (see Eosinophilia-Myalgia Syndrome, [[Eosinophilia-Myalgia Syndrome]])
    • Physiology: due to contaminated L-tryptophan (see L-Tryptophan, [[L-Tryptophan]])
  • Toxic Rapeseed Oil Syndrome (see Contaminated Rapeseed Oil, [[Contaminated Rapeseed Oil]])
    • Physiology: due to contaminated rapeseed oil

Eosinophilic Pulmonary Syndromes of Unknown Etiology

Other Pulmonary Disorders with Possible Associated Pulmonary Eosinophilia

  • Asthma (see Asthma, [[Asthma]])
  • Eosinophilic Bronchitis (see Eosinophilic Bronchitis, [[Eosinophilic Bronchitis]])
    • Clinical: chronic cough with sputum eosinophilia (about 40%)
      • Normal Lung Function with Absence of Bronchial Hyperreactivity: although it may evolve over time into either fixed airflow obstruction without asthma or into true asthma
      • Absence of Eosinophilic Pneumonia
  • Gastric Cancer with Tumor-Related Production of GM-CSF and IL-5 (see Gastric Cancer, [[Gastric Cancer]])
    • Epidemiology: case report
  • Hematopoietic Stem Cell Transplant (HSCT) (Bone Marrow Transplant, BMT) (see Hematopoietic Stem Cell Transplant, [[Hematopoietic Stem Cell Transplant]])
    • Epidemiology: xxxx
  • Hodgkin’s Disease (see Hodgkins Disease, [[Hodgkins Disease]])
    • Epidemiology: xxxx
  • Idiopathic Interstitial Pneumonias
    • Desquamative Interstitial Pneumonia (DIP): mild BAL eosinophilia may occur in some cases
    • Non-Specific Interstitial Pneumonia (NSIP): mild BAL eosinophilia may occur in some cases
  • Idiopathic Pulmonary Fibrosis (IPF) (see Idiopathic Pulmonary Fibrosis, [[Idiopathic Pulmonary Fibrosis]]): mild BAL eosinophilia may occur in some cases
  • Langerhans Cell Histiocytosis (LCH) (see Langerhans Cell Histiocytosis, [[Langerhans Cell Histiocytosis]])
    • Diagnosis: pulmonary pathologic lesions are nodules (with bronchiolocentric stellate shape) with Langerhans cells and variable numbers of eosinophils, plasma cells, and lymphocytes
      • Eosinophils are Usually Present in the Initial, Active Stage of the Disease: they contribute to the eosinophilic granuloma
      • Eosinophils are Numerous in 25% of Cases: usually located at the periphery of the lesions
      • Eosinophils are Rare or Absent at the Chronic Stage of the Disease
  • Lung Transplant (see Lung Transplant, [[Lung Transplant]])
    • Acute Lung Transplant Rejection (Acute Cellular Lung Transplant Rejection) (see Acute Lung Transplant Rejection, [[Acute Lung Transplant Rejection]]): peripheral eosinophilia may occur with/without pulmonary infiltrates (as acute rejection may be detected by surveillance bronchoscopy with transbronchial biopsy prior to the development of pulmonary infiltrates)
  • Organizing Pneumonia (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
    • Diagnosis: mild BAL eosinophilia may occur in some cases (usually <20%)
  • Sarcoidosis (see Sarcoidosis, [[Sarcoidosis]])
    • Diagnosis: peripheral eosinophilia (and tissue eosinophilia) may be present, but are usually mild

Etiology of Bronchoalveolar Lavage (BAL) with Hemosiderin-Laden Macrophages (>20%)

Other Abnormal Bronchoalveolar Lavage (BAL) Findings (Am J Respir Crit Care Med, 2012) [MEDLINE]

  • Infectious Organism: indicates presence of lower respiratory infection
  • Malignant Cells (by Light Microscopy or Flow Cytometry): indicates cancer
  • Bloody BAL Fluid in Successive Aliquots: indicates pulmonary hemorrhage (with/without diffuse alveolar hemorrhage)
  • Milky Fluid with Positive Periodic Acid Schiff (PAS-Positive) Staining and Amorphous Debris: indicates pulmonary alveolar proteinosis
  • In Vitro Lymphocyte Proliferative Response to Specific Beryllium Antigen: indicates chronic beryllium disease

Recommendations for Bronchoalveolar Lavage (BAL) in the Setting of Interstitial Lung Disease (Am J Respir Crit Care Med, 2012) [MEDLINE]

  • For Patients with Suspected Interstitial Lung Disease in Whom a Bronchoalveolar Lavage Can Be Tolerated, BAL Target Site Be Chosen on the Basis of an HRCT Performed Before the Procedure, Rather than Choosing a Traditional Bronchoalveolar Lavage Site (Such as the Right Middle Lobe or Lingula)
    • HRCT Should Be Performed within 6 wks of the BAL
  • For Patients with Suspected Interstitial Lung Disease Who Undergo Bronchoalveolar Lavage, a Differential Cell Count Should Be Performed on the Bronchoalveolar Lavage Fluid
    • Including Lymphocyte, Neutrophil, Eosinophil, and Mast Cell Counts
    • Remaining Sample Should Be Used for Microbiological, Virological, and/or Malignant Cell Cytology Laboratory Testing, if Indicated
  • For Patients with Suspected Interstitial Lung Disease Who Undergo Bronchoalveolar Lavage, Lymphocyte Subset Analysis Should Not Be a Routine Component of Bronchoalveolar Lavage Cellular Analysis

Complications of Bronchoscopy (Respirology, 2012) [MEDLINE]

Complication Rate by Pulmonary Lesion

  • General Comments
    • Overall Complication Rate: 0.51%-2.06% (with highest rates being reported for diffuse pulmonary lesions)
    • Complication Rate by Procedure: 0.17%-1.93% (with highest rates being reported for forceps biopsy)
    • Bronchoscope/Device Breakage: reported in 47.2% of centers
      • Patient Biting of Bronchoscope
      • Needle Perforation of Forceps Channel
      • Heat Damage to Bronchscope (During Laser, etc)
      • Malfunction of Biospy Forceps
      • Curette Breakage
  • Airway Perforation
    • Reported Frequency (with central airway lesions): 0%
    • Reported Frequency (with hilar/mediastinal lesions): 0%
    • Reported Frequency (with solitary pulmonary lesions): 0%
    • Reported Frequency (with diffuse pulmonary lesions): 0%
  • Cardiovascular Event: arrhythmias, myocardial infarction, etc
    • Reported Frequency (with central airway lesions): 0.05%
    • Reported Frequency (with hilar/mediastinal lesions): 0%
    • Reported Frequency (with solitary pulmonary lesions): 0.08%
    • Reported Frequency (with diffuse pulmonary lesions): 0.04%
  • Bronchospasm (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
    • Reported Frequency (with central airway lesions): 0.09%
    • Reported Frequency (with hilar/mediastinal lesions): 0.02%
    • Reported Frequency (with solitary pulmonary lesions): 0.06%
    • Reported Frequency (with diffuse pulmonary lesions): 0.08%
  • Central Airway Obstruction
  • Death
    • Reported Frequency: 0.004%
  • Hemorrhage
    • Reported Frequency (with central airway lesions): 0.89%
    • Reported Frequency (with hilar/mediastinal lesions): 0.30%
    • Reported Frequency (with solitary pulmonary lesions): 0.63%
    • Reported Frequency (with diffuse pulmonary lesions): 0.44%
  • Infection (see Pneumonia, [[Pneumonia]])
    • Reported Frequency (with central airway lesions): 0.15%
    • Reported Frequency (with hilar/mediastinal lesions): 0.15%
    • Reported Frequency (with solitary pulmonary lesions): 0.25%
    • Reported Frequency (with diffuse pulmonary lesions): 0.21%
  • Lidocaine Toxicity
    • Reported Frequency (with central airway lesion): 0.03%
    • Reported Frequency (with hilar/mediastinal lesions): 0.02%
    • Reported Frequency (with solitary pulmonary lesions): 0.04%
    • Reported Frequency (with diffuse pulmonary lesions): 0.05%
  • Pneumothorax (see Pneumothorax, [[Pneumothorax]])
    • Reported Frequency (with central airway lesions): 0.004%
    • Reported Frequency (with hilar/mediastinal lesions): 0%
    • Reported Frequency (with solitary pulmonary lesions): 0.44%
    • Reported Frequency (with diffuse pulmonary lesions): 0.87%
  • Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
    • Reported Frequency (with central airway lesions): 0.03%
    • Reported Frequency (with hilar/mediastinal lesions): 0.02%
    • Reported Frequency (with solitary pulmonary lesions): 0.04%
    • Reported Frequency (with diffuse pulmonary lesions): 0.36%

Complication Rate by Procedure

  • Hemorrhage
    • Reported Frequency (with simple bronchoscopy): 0.14%
    • Reported Frequency (with forceps biopsy): 0.85%
    • Reported Frequency (with brush biopsy): 0.25%
    • Reported Frequency (with bronchoalveolar lavage): 0.02%
    • Reported Frequency (with transbronchial needle aspiration): 0.28%
    • Reported Frequency (with EBUS-TBNA of hilar/mediastinal lesions): 0.71%
  • Pneumothorax (see Pneumothorax, [[Pneumothorax]])
    • Reported Frequency (with simple bronchoscopy): 0.05%
    • Reported Frequency (with forceps biopsy): 0.67%
    • Reported Frequency (with brush biopsy): 0.03%
    • Reported Frequency (with bronchoalveolar lavage): 0.008%
    • Reported Frequency (with transbronchial needle aspiration): 0.07%
    • Reported Frequency (with EBUS-TBNA of hilar/mediastinal lesions): 1.52%

References

  • The BAL Cooperative Group Steering Committee. Bronchoalveolar lavage constituents in healthy individuals, idiopathic pulmonary fibrosis, and selected comparison groups. Am Rev Respir Dis. 1990;141(5 pt 2):S169-S202
  • Deaths and complications associated with respiratory endoscopy: a survey by the Japan Society for Respiratory Endoscopy in 2010. Respirology. 2012 Apr;17(3):478-85. doi: 10.1111/j.1440-1843.2011.02123.x [MEDLINE]
  • An Official American Thoracic Society Clinical Practice Guideline: The Clinical Utility of Bronchoalveolar Lavage Cellular Analysis in Interstitial Lung Disease. Am J Respir Crit Care Med. 2012 May 1;185(9):1004-14. doi: 10.1164/rccm.201202-0320ST [MEDLINE]