The investigation of bronchoalveolar lavage fluid in paediatric chronic wheezers

Marshall, Michelle Anthea (2020-03)

Thesis (MMED)--Stellenbosch University, 2020.

Thesis

ENGLISH ABSTRACT: Background: Paediatric broncho-alveolar lavage (BAL) is a minimally invasive procedure, performed during flexible bronchoscopy using isotonic saline to obtain a sample of bronchial and alveolar fluid from the distal lung. The BAL sample provides a determination of the different cell types that are present in the alveolar space as well as establishing the presence of lipid or haemosiderin in alveolar macrophages. In paediatric clinical practice, the patients that undergo BAL most frequently are children with chronic wheezing and recurrent chest infections as part of their workup to determine the possible cause. However, the interpretation of these results, in the clinical context is relatively uncertain. We therefore conducted this study in collaboration with the paediatric pulmonology unit at Tygerberg hospital in an attempt to determine if the BAL specimens can be used to categorize children with wheezing into either a gastro-eosophageal reflux or primary respiratory pathology group. We wanted to guage whether laboratory tests such as the differential cells counts; lipid-laden macrophage index, haemosiderin-laden macrophages index and number of carbon-laden macrophages can be used as a marker for pulmonary pathology. To determine if BAL can assist with sub-classification of the primary respiratory pathology group and determine if the amount of carbon-laden macrophages corresponds to the risk of increased lung disease Aim: Henceforth, we undertook this study to determine if the BAL specimens could be used to categorize these children as belonging to either the gastro-esophageal reflux or primary respiratory pathology group by grading the amounts of Oil red O lipid-laden macrophages (LLM) which is a marker for gastro-oesophageal reflux aspiration , Perl’s Prussian blue positive haemosiderin-laden macrophages(HLM) which serves to indicate the presence of pulmonary haemorrage and carbonladen macrophage (CLM) which may contribute to chronic lung disease, however has not yet been assessed in our setting. We also wanted to determine if the amount of phagocytosed carbon by alveolar macrophages had any correlation with chronic wheezing. Methods: Between march 2017 and march 2018, 68 paediatric patients presenting with a chronic wheeze underwent clinical investigations which included routine chemical pathology, microbiology and virology testing and the cytological evaluation of their BAL specimens. Once processed, the slides were stained with the Papanicolaou, Giemsa, Oil red O and Perl’s Prussian blue to quantitate the differential cell count as well as lipid-laden macrophage index, haemosiderin-laden macrophage index and number of carbon-laden macrophages present. After a full clinical work-up, these patients were placed into a broad category of recurrent wheeze and recurrent infection, and sub-category groups of gastro-eosaphageal reflux disease (GORD), alveolar proteinosis, idiopathic pulmonary haemosiderosis (IPH), recurrent wheeze, infection/inflammation and structural abnormalities. Results: There was no statistical significance when comparing the cellular differential counts; carbon; lipid and haemosiderin-macrophages; tuberculosis investigations; cystic fibrosis investigations; virology investigations; microbiology investigations and c-reactive protein in the broad categories of recurrent wheezer vs. recurrent infection as well as subcategories of infection/inflammation, GORD, structural abnormality, idiopathic wheezer, IPF and alveolar proteinosis. Conclusion: The cytological investigation of paediatric BAL specimens continues to play a role in the clinical work up of children with chronic wheezing. This study did not manage to yield statistically significant data to identify a specific underlying cause and further research is needed in this field.

AFRIKAANSE OPSOMMING: Agtergrond: Pediatriese brongo-alveolêre spoeling (BAS) is 'n minimaal indringende prosedure wat uitgevoer word tydens buigsame brongoskopie met behulp van isotoniese soutoplossings om 'n monster van brongiale en alveolêre vog te verkry. Die BASmonster help met die bepaling van die oorheersende seltipe en die bepaling van die teenwoordigheid van lipied of hemosiderien in alveolêre makrofage. In die kliniese praktyk is die pasiënte wat BAS gereeld ondergaan, kinders met chroniese fluit en herhalende borskasinfeksies as deel van hul kliniese ondersoek om die moontlike oorsaak te bepaal. Die interpretasie van hierdie resultate in die kliniese konteks is egter betreklik onseker. Daarom het ons hierdie studie in saamwerking met die pediatriese pulmonologie-eenheid in die Tygerberg hopitaal uitgevoer in ‘n poging om vas te stel of die BAS monster kan gebruik word om kinders met ‘n chroniese fluit in ‘n gastro-oesofiese refluks of ‘n primêre repiratoriese patologiegroep te kategoriseer. Ons wou vasstel laboratoriumtoetse soos die differensiële seltelling olie-rooi O-lipiedbelaaide makrofage, pruisiese blou positiewe hemosiderien belaaide makrofage en koolstof belaaide makrofage kan gebruik word as ‘n merker vir pulmonale patologie. Om vas te stel of BAS kan help met die subklassifikasie van die primêre repiratoriese patologiegroep en bepal of die nommer van koolstof belaaide makrofage ooreenstem met die risko van verhoogtde longsiekte. Doelwitte: Ons het hierdie studie onderneem om te bepaal of die BAS-monsters gebruik kan word om hierdie kinders te kategoriseer onder die gastro-esofageale refluks- of primêre respiratoriese patologiegroep. Daarvoor word die aantal olie-rooi O-lipiedbelaaide makrofage (LLM), Pruisiese blou positiewe hemosiderien belaaide makrofage (HLM) en koolstof belaaide makrofage (CLM) bepaal. Ons wou ook vasstel of die aantal gefagositeerde koolstof in alveolêre makrofage met chroniese fluit verband hou. Metodes: Tussen 13-Mar-2017 en-12-Mrt-2018, het 68 pediatriese pasiënte wat chroniese fluitbors gehad het, kliniese ondersoeke ondergaan wat roetine chemiese patologie, mikrobiologie en virologie-toetse en die sitologiese evaluering van hul BAS-monsters insluit. Nadat die skyfies gemaak is, is hulle met papanicolaou, giemsa, olie-rooi O en Pruisiese blou van Perl gekleur om die differensiële seltelling asook indekse van olie-rooi O-lipiedbelaaide makrofage, pruisiese blou positiewe hemosiderien belaaide makrofage ,en koolstof belaaide makrofage te kwantifiseer. Die beoordeling van die spesiale kleurmetodes is uitgevoer. Na 'n volledige kliniese ondersoek, is hierdie pasiënte in 'n breë kategorie van herhalende fluit en herhalende infeksie geplaas, en sub-kategorieë gastro-esofageale reflukssiekte alveolêre proteïnose, idiopatiese pulmonale hemosiderose (IPH), herhalende fluit, infeksie / ontsteking en strukturele abnormaliteite. Resultate: Daar was geen statistiese beduidende resultate by die vergelyking van sellulêre differensiaalgetalle nie; koolstof; lipied- en hemosiderien-makrofage; tuberkulose ondersoeke; sistiese fibrose ondersoeke; virologiese ondersoeke; mikrobiologiese ondersoeke en c-reaktiewe proteïen in die breë kategorieë van herhalende fluitwaarde vs herhalende infeksie, sowel as subkategorieë van infeksie / inflammasie, gastro-esofageale reflukssiekte, strukturele abnormaliteite, idiopatiese fluit, IPF en alveolêre proteïnose. Gevolgtrekking: Die sitologiese ondersoek van pediatriese BAS-monsters speel steeds 'n rol in die kliniese opbou van kinders met chroniese fluit. Hierdie studie het nie statisties geslaag om ‘n spesifieke onderliggende oorsaak te identifiseer nie en verdere navorsing op hierdie gebied is nodig.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/108074
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