After an increase in microvascular filtration rate, lung lymph may contain protein washed from the tissue spaces plus protein from the filtrate. If so, then the lymphatic protein concentration may be significantly higher than the filtrate protein concentration (Cf). To test this hypothesis, we decreased the plasma protein concentration from 5.1 +/- 0.6 to 0.54 +/- 0.15 g/dl and increased the pulmonary microvascular filtration rate in four dogs. We estimated Cf to be 0.16 +/- 0.05 g/dl after we reduced the plasma protein concentration, and the lymphatic protein concentration (0.43 +/- 0.04 g/dl) was significantly greater than Cf. Our results indicate that lung microvascular membrane reflection coefficients estimated from lung lymph data may be too low. However, the amount of error caused by tissue protein washout is probably small. To account for the protein washout error, we estimated the lung microvascular membrane reflection coefficient to be approximately 0.74-0.76 instead of the approximately 0.70 previously reported for dogs (J. C. Gabel et al. J. Appl. Physiol. 55: 866-869, 1983).
Background and objective Cellular analysis of bronchoalveolar lavage (BAL) fluid may aid diagnosis in patients with undifferentiated interstitial lung disease (ILD). The utility of this test in the diagnostic process in conjunction with a multidisciplinary discussion (MDD) is not known. We aim to assess and compare interobserver agreement and diagnostic confidence before and after presenting BAL results in an ILD-MDD. Methods Patients undergoing investigations for ILD at Waikato Hospital were recruited. At the ILD-MDD two respiratory physicians and one respiratory radiologist participated in the discussion, and their diagnosis and diagnostic confidence were assessed at four sequential time points. Assessors were blinded to each others diagnosis and diagnostic confidence scores. The four sequential time points were (1) after clinical and radiology presentation; (2) after subsequent MDD; (3) after reviewing BAL results; (4) after final MDD with all results. Interobserver agreements were calculated using Fleiss κ statistic. Results 36 patients were recruited, and 77.8% were male. In the first step, the interobserver agreement was substantial κ = 0.622 (95% CI 0.47–0.77), improving in step 2 following MDD to κ = 0.78 (95% CI 0.624–0.935), in step 3 κ = 0.776 (95% CI 0.614–0.937) and step 4 achieved almost perfect agreement of κ = 0.969 (95% CI 0.828-1.11). The diagnostic confidence for individual and group diagnosis increased with the presentation of BAL with and without multidisciplinary MDD. Conclusion We found that BAL cellular analysis improves interobserver agreement and confidence in diagnosis following MDD, thus aiding decision-making in cases with undifferentiated ILD.
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