Therapeutic applications of BAL.

Although BAL had been used for therapeutic purposes prior to its use as a diagnostic procedure and the value of BAL in the exploration and management of some interstitial lung diseases is now well established, its place in therapy is controversially reported. As early as 1963, RAMIREz et al. [280] were the frrst to perform a whole lung lavage (WLL) using a large volume of fluid in patients with pulmonary alveolar proteinosis. Since then, this technique has been proposed to remove any alveolar filling material in conditions such as alveolar proteinosis [196, 281], alveolar microlithiasis [282], acute silicosis [283], or accidental inhalation of radioactive particles [289, 205]. Its use has also been proposed in obstructive lung diseases [286] to remove the mucus secretions accumulated in the bronchial tree as in asthma [287, 288) or in cystic fibrosis [289, 290]. This lavage differs from the segmental BAL currently used for diagnostic or research purposes in that it is performed under general anaesthesia, and uses a much larger fluid volume. The actual procedure varies slightly from one centre to another and has not yet been standardized [196, 291]. WLL is a safe procedure as shown by the absence of chronic side-effects over periods as long as 25 yrs in patients treated for pulmonary alveolar proteinosis (PAP) [192]. On the other hand, its efficacy is known to be dependent on the type of disorder in which it is performed. We will briefly review the main pathological conditions in which WLL is currently performed.