Conclusions.
BAL has been widely used during the SARS-Cov-2 pandemic for both
clinical and research purposes. In clinical practice BAL can change
management decisions in up to two-third of patients confirming a
suspected SARS-Cov-2 infection when the NP swab is negative, detecting
other infections or supporting alternative diagnosis. Although studies
have a wide variability, a pooled estimates of 11% positive cases
suggest that BAL can be used to confirm suspected SARS-Cov-2 infection
when negative NP swab is negative.19 The prevalence of
false negative BAL for SARS-Cov-2 detection can’t be accurately drawn
from current studies, but seems to be very low
(<2%).25 In both critically ill and
non-critically ill patients, BAL detects coinfections a significant
proportion of patients. BAL can help clinicians in difficult
differential diagnosis including acute exacerbations of interstitial
lung diseases (ILDs), connective tissue related ILDs, hypersensitivity
pneumonitis, cryptogenic organizing pneumonia. BAL analyses are used to
guide steroid and immunosuppressive treatment and to narrow or
discontinue antibiotic treatment reducing the use of unnecessary broad
antibiotics. Moreover, cellular analysis and novel multi-omics
techniques on BAL are of critical importance for the understanding of
the microenvironment and interaction between epithelial cells and
immunity revealing novel potential prognostic and therapeutic targets.
The BAL technique has been described as safe for both patients and
health care workers in more than a thousand procedures reported to date
in the literature. Based on these preliminary studies, we recognize that
BAL is a feasible procedure in COVID-19 known or suspected cases, useful
to properly guide patient management and with great potential for
research. Based on the evidences here summarized, we propose a
simplified diagnostic algorithm in which BAL can be used in suspected
COVID-19 cases when the NP swab is negative, and in COVID-19 cases to
guide antimicrobial and steroid treatment when a coinfection is
suspected (Figure 1). We acknowledge that this algorithm reflects the
clinical practice only in selected centres properly equipped and
experienced in the use of BAL and that further large prospective studies
are needed to corroborate current knowledge before BAL can be widely
recommended.
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