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BAL is a useful technique to obtain cytological and biochemical information in response to infections or drugs. Initially, BAL was used to manage the excessive mucus production in human patients suffering from phosgene toxicity3. Nowadays, the technique is used in humans to investigate lung pathogenesis, diagnosis, and therapeutic management of diseases3,24. In laboratory animals, BAL is commonly used to monitor inflammatory responses, immune mechanisms, and infectious disease processes that occur in the pulmonary airways1,2.
To study the inflammatory cellular pattern in respiratory disease models, BAL should be followed by absolute and differential cell counting. In addition to the absolute cell number, the relative cell numbers are also of interest. For example, repair and cancer models show very small to no BAL cell count increases. In this model, the assessment of cellular composition is useful. By using cell staining combined with light microscopy, different cell types, such as eosinophils, neutrophils, macrophages, and lymphocytes, can be identified based on morphology25,26,27,28,29,30. Flow cytometry can be used for specific assessments, such as to identify different T-cell phenotypes7,31. In addition to the identification of the different infiltrating cell populations, the non-cellular composition of the lung can be investigated using BAL. Methods such as ELISA, immunoblot, cytokine bead array, immunohistochemistry, and quantitative polymerase chain reaction are performed on BAL fluid to determine cytokines, growth factors, and other inflammatory components. To determine lung damage, total protein and lactate dehydrogenase levels in the BAL fluid can also be measured32,33.
With the development of new diagnostic tools, the genomic and proteomic characterization of BAL components will be possible in the near future. The combination of expanding computational capabilities and high-throughput gene expression technologies will make it possible to define specific gene expression profiles for various disease states. Performing these techniques on BAL fluid can provide gene and protein expression patterns to identify the important molecules involved in the different phases of lung diseases.
The main limitation of data obtained from BAL fluid is the lack of comparability between different research trials3,9. There is a high degree of variability in the lavage technique and the subsequent processing of BAL fluid. To be able to compare each BAL trial, it is necessary to standardize the type of lavage fluid that is instilled, the site of instillation, and the fraction that is to be analyzed for cellular and non-cellular composition. There are significant differences in the number of lavage fractions between different trials, varying from one to 14 times34,35,36. This difference may have an impact on the estimated total cell numbers in the lungs. It is important to know which BAL fluid fraction contains the majority of cells. Song et al. showed that approximately 70% of the total number of cells were retrieved in fraction one to three22. However, other reports suggested that the second lavage contained more cells than the first one37,38. We can conclude from these studies that a lavage with just one fraction does not represent the whole lung, leading to misinterpretation of the results.
The noncellular composition of the BAL fluid contains valuable information on the health status of the lung33,39,40. Variations in the dilution of the BAL fluid contributes to the difference in the quantification of the soluble fraction and, consequently, to differences in the results between trials. Song et al. compared the protein and lactate dehydrogenase levels of each lavage fraction and concluded that the first lavage fraction contained two to three times more than the second fraction.
To retrieve a representative BAL sample for analysis, some technical considerations are crucial. One of them is to perform proper anesthetization. It is very important to check the foot reflex of the mouse to ensure terminal sedation. This is not only important for ethical reasons, but also because it is difficult to place and retain the catheter in the correct position if the mouse is not properly anesthetized.
A second important technical consideration is the position of the catheter in the trachea. When the catheter is inserted too deep, it can damage the lung structure. The distal end of the catheter should not reach the lungs during the BAL procedure. The catheter should also be stabilized and tied off with a cotton thread. If the catheter is not stabilized, the injected saline solution may flow upwards into the nasal cavity instead of down into the lungs. During injection and aspiration of the saline solution, it is important to hold the catheter steady.
The data obtained from the BAL fluid must represent the whole murine lung. Therefore, it is important to instill an adequate volume of saline buffer (i.e. 3 mL, divided in 3 aliquots of 1 mL each). There is no linear relationship between the cell yield and the BAL fluid yield. It is important to collect the solution gently while massaging the thorax of the mouse. If shearing forces are too strong, the viability, function, and structure of cells within the airways and BAL fluid may be compromised. If the aspirated fluid is not visible in the syringe, carefully move the catheter deeper or higher in the trachea.
Special notice should be given to specific aspects of BAL processing and analysis. This will maximize the information retained from BAL samples. After BAL, the cells are in a nutrient-poor saline medium. It is therefore very important to process the samples within 1 h after BAL sampling. If prolonged storage is necessary, the use of a nutrient-supplemented medium is required.
To preserve cell viability, avoid tubes that promote cell adherence to the surface. Avoid centrifugation of cell suspensions at speeds that are likely to compromise cellular integrity or to prevent uniform resuspension of the retrieved BAL cells. BAL fluid containing cells should be centrifuged at 400 x g and 4 °C for 7 min. It is important to keep in mind that cell suspensions should be held at 4 °C during processing.