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Version: This replaces the Induced Sputum Guidelines for Practice, May 2012
Review Date: October 2018
Contact: Greg Stretton, Senior Physiotherapist Specialty Medicine Cancer Services
and Eleanor Douglas, Lecturer/Practitioner Physiotherapist Ext: 55292 / 56142
Disclaimer
This guideline has been registered with the Nottingham University Hospitals Trust.
However, clinical guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual clinician. If in any
doubt regarding this procedure, contact a senior colleague. Caution is advised when
using guidelines after the review date. Please contact the named above with any
comments / feedback. Please note this guideline is for sputum induction in adults
only.
Precautions
Asthma – the induced sputum procedure can cause bronchospasm so known
asthmatics should be monitored throughout for signs of intolerance.
High percentage oxygen support (>40%) – the induced sputum procedure requires
the ultrasonic nebulizer which does not have a high flow-rate. Therefore it cannot be
used in conjunction with oxygen via a T-piece. If a patient requires oxygen they
must be on either nasal cannula or nasal optiflow.
These factors need to be weighed up against the clinical need for a sputum sample.
Contraindications
Pulmonary Embolism
Cardiovascular instability
Pneumothorax
Fractured ribs / chest trauma
Bronchospasm
Patient is independently expectorating
Patient has eaten within 4 hours
Equipment List
Please note the use of 7% NaCl can be negotiated with the requesting consultant.
There is no acknowledged ideal concentration of NaCl for an induced sputum, varying
from 3-10% (Bell et al, 2004). NUH uses 7% as a standard because it is readily
available from pharmacy and has caused less cancellations. Previously NUH has
used lower NaCl solutions, requested from pharmacy, but this often led to the
procedure being cancelled due to the unavailability of the Nacl solution.
Procedure - Preparation
Action Rationale
Ensure a referral has been made Induced sputum requests must be through a
by a doctor (SHO or above) and medical referral.
has been documented in the
medical notes.
The procedure has been Minimizes distress and informs the patient of the
explained to the patient and procedure. Confirms the patient is willing to
consent has been given. undertake the procedure.
The patient must be nil-by- To prevent the patient from vomiting and
mouth for 4 hours prior to the contaminating the sputum samples. It is
Procedure – Pre-Nebulisation
Obtain consent from the patient Confirms the patient is still willing to undertake
on the morning of the the procedure.
investigation.
Sit the patient upright in a chair Provides a good position for the patient when
or on their bed. they are coughing.
The patient should be given This significantly reduces the likelihood of
2.5mg Salbutamol prior to the bronchospasm (Pizzichini et al, 2002).
induced sputum if cardiovascular Haematology doctors may not be happy with the
status allows. NB. If the patient cardiovascular risk out-weighing the
is under a Haematologist, please bronchospasm benefit of pre-nebulisation.
check with the haematology
doctor that they are in agreement
with this.
Ensure a PRN Salbutamol 2.5mg Salbutamol must be available incase the
nebuliser has been prescribed and procedure induces bronchospasm (Leigh et al
it setup so that it can be used 1994 and Castagaro et al 1999).
quickly in an emergency.
Gloves, apron and a, FFP3 facial- This reduces the amount of nebulised saline
mask should be worn by the inhaled by the therapist and protects them from
physiotherapist during the any harmful airborne particles expectorated by
procedure. the patient.
Auscultate the patient’s chest. To ensure no bronchospasm is present.
Set up the ultrasonic nebuliser To avoid contamination.
using sterile water in the
chamber, the amount of which is
indicated on the side of the
chamber.
Place a disposable cup in the top To avoid contamination and ensure saline
of the ultrasonic nebuliser and fill administered is of correct dosage and
with 28mls of hypertonic saline. concentration and that it has not expired
The saline should be double
checked with 2 qualified members
of staff to confirm expiry date,
correct dosage and concentration
prior to administration
Place the filter on the ultrasonic This reduces the likelihood of external infectious
between the base and the shorter agents being passed into the patient.
Monitor the patient’s oxygen Desaturation during the procedure may occur
saturations during the procedure (Leigh et al 1994; Castagnaro et al 1999)
and provide supplementary
oxygen via nasal cannula if
saturations drop below patient’s
normal range.
After the 1st minute, auscultate Bronchospasm can occur at any time and can
the patient to assess whether present very quickly. All patients should be
there is any bronchospasm monitored throughout the procedure. If any
present. This should also be signs of bronchospasm present, stop the
done, regardless of time, if the investigation and immediately commence the
patients sounds wheezy or reports second Salbutamol neb.
tightness.
If the patient appears in If bronchospasm occurs, the patient may require
respiratory distress, ie. Increased higher amounts of Oxygen to remain within their
work of breathing, bronchospasm normal SpO2 range.
and reduced SpO2, stop the
hypetonic saline and give the PRN
Salbutamol via 6-10l of O2, to
bring the SpO2 back into a normal
range.
Allow the patient to inhale the To illicit a spontaneous cough.
nebuliser for 20-30 minutes, or
until it has all been inhaled,
temporarily stopping it when the
patient expectorates (Scheicher et
al, 2003).
If a cough is not elicited gentle To try to mobilise secretions in order to gain the
vibrations or percussion over the sputum specimens.
patients chest can be carried out
in sitting or side lying unless
patient has any contraindicating
factors e.g. rib Fractures
References
Leigh TR, Kirby K, Gazzard BG and Collins JV. Effects of sputum induction on arterial
oxygen saturation and spirometry in HIV infected patients. European Respiratory
Journal 1994. 7(3): 453 458
McWilliams T, Wells AU, Harrison AC, Lindstrom S, Cameron RJ, Foskin E. Induced Sputum
and bronchoscopy in the diagnosis of pulmonary tuberculosis. Thorax 2002; 57(12): 1010-1014
Paggiaro PL, Chanez P, Holz O, Ind PW, Djukanovic R, Maestrelli P and Sterk PJ.
Sputum induction. European Respiratory Journal 2002 20: Supple. 37: 3 – 8.
Pizzichini E, Leigh R, Djukanovic R and Sterk PJ. Safety of induced sputum. European
Respiratory Journal 2002 20: Supple. 37: 9 – 18.
Pryor JA and Prasad AS. Physiotherapy for Respiratory and Cardiac Problems.2002.
Third Edition. Churchill Livingstone. Chapter 6
Marcos Eduardo Scheicher ME, Filho JT, Vianna EO Sputum induction: review of
literature and proposal for a protocol. Sao Paulo Med Journal 2003; 121(5):213-219