• Some clinicians like to pre-medicate the patient with inhaled or parenteral bronchodilators
  to reduce the risk of bronchospasm.
•  If one side of the pulmonary field appears to have more marked changes, place the patient
  in lateral recumbancy with this side lowermost, as there is a chance that gravity will take the
  tube to this side.
•  Gold standard is often considered to BAL from 2 sites (eg left and right lung fields). However
  this may not alter diagnosis and the increased cost and minor increase in risks should be
  considered.
• Warming the flush fluid decreases the chance of bronchospasm and helps to increase cell
  yield
• A frothy sample suggests the alveolar space has been sampled (froth = presence of
  surfactant). Turbid, flocculent samples are often diagnostic. If yield appears to be poor in
  quantity or quality, it can be increased by performing the flush 2-3 times in the same area
• Total maximum 2ml/kg saline flush is recommended, split this into 2-3 aliquots.
  This is important for cats and small dogs. Large dogs rarely require as much as 2ml/kg saline
  to provide sufficient sample.
• Poor yield may reflect the presence of thick discharge which is difficult to aspirate. Larger
  bore sampling tubes may be worth a try: they will not reach as far into the bronchial tree,
  but, they will be more successful in collecting thick, viscous material.
• Very thick mucus in the sample may “trap” diagnostic cells and remove them from
  cytological analysis. It can help to make a smear from a small amount of mucopurulent
  material in such a case.
• A light plane of anaesthesia is often preferred as this is less likely to suppress coughing. A
  little coughing can aid fluid and cellular yield. A short mouth gag without a spring is safe and
  protects the ET tube.
• If a connector with a capped port is unavailable, flow-by oxygen should be provided during
  the procedure if it becomes more protracted than expected. Increments of intravenous
  anaesthetic can be administered, (or total intravenous anaesthesia used), but note that BAL
  is typically a rapid procedure; a duration sufficient to cause hypoxia would be unusual.
  

In case of complication:

• Both bronchospasm and pneumothorax will present in a similar manner, with hypoxia,
  respiratory compromise and resistance to intermittent positive pressure ventilation.
  Bronchospasm typically occurs at the time of BAL, pneumothorax may occur immediately or
  develop more slowly.
• Intravenous terbutaline (*NB off-licence) can be used to reverse bronchospasm (expect
  tachycardia).
• Thoracic radiography can be undertaken to detect pneumothorax but diagnostic
  thoracocentesis is quicker, and can progress easily to a therapeutic procedure.
• Typically pneumothorax can be successfully treated with a single thoracocentesis only.
  Access to a chest drain (eg MILA – simple to place), would be advisable as a precaution
  NB Complications of BAL are rare and in the vast majority of cases, can be treated successfully and
  with ease. Just be prepared!