There is often a complementary role of bronchial washing (BW) or bronchoalveolar lavage (BAL), bronchial brushing, and endobronchial biopsy (EBBX). One or more of them is performed with transbronchial needle aspirate and transbronchial lung biopsy. This review is to provide the bronchoscopist a practical guide to procedural decision making in terms of specimen collection and diagnostic approach. Each of these procedures will be defined and techniques discussed. The role they play in diagnosis alone or in combination in infectious disease, drug-induced lung disease, inflammatory and occupational lung disease, and in malignant diseases is explained. General indications for these procedures, identification of key elements of specimen collection methods, diagnostic information that can be obtained, and advances in technology is reviewed.

When approaching the patient with an abnormal chest radiograph or computed tomography (CT) scan, it is important to plan a strategy of questions to be answered and specimens to be collected well before the bronchoscopic procedure even begins. It is worthwhile to create a broad differential diagnosis based on the patient history specifically in terms of immunocompetence, medication and environmental exposures, infectious contacts, and travel. Risk factors for malignancy should be assessed. Chest imaging will identify extent and location of disease. These variables will determine the bronchoscopic tests to be ordered and the location of the sample to be obtained as well as the quantity of specimen required.