SPUTUM EXAMINATION

Sputum:

One of the most common types of specimen submitted to the laboratory

for bacterial examination.

Difficult to obtain because of contamination with saliva.

Even specimens collected by bronchoscopy or through an endotracheal

tube may be mixed with oropharyngeal secretions.

Many of the bacteria which are known to cause lower respiratory tract
infections may be present in the oropharynx as part of the normal flora
e.g., staphylococci, pneumococci, and gram negative rods.

The examination of a direct smear from the specimen can be very helpful
in diagnosing respiratory infections and in determining the usefulness of
the information provided by the culture.
Sputum collection

 Mouth should be free of foreign objects

 Early morning specimen is best
 Induce sputum if necessary
 Nebulized hypertonic saline or
distilled water
 Chest percussion
Estimate daily volume of Sputum

 Small amounts
 Lung Abscess
 Pneumonia
 Tuberculosis
 Copious amounts (>200 cc/day)
 Bronchiectasis
 Bronchopleural Fistula
Sputum Color

 Bloody Sputum (Hemoptysis)

 Rusty Sputum (Prune-juice)
 Pneumococcal Pneumonia
 Purulent Sputum (yellow, green, dirty-
gray)
 Color alone does not distinguish
bacterial infection
Sputum Turbidity

 Frothy Sputum (air bubbles,

Hemoglobin)
 Pulmonary edema
 Foamy, clear material
 Saliva
 Nasal secretions
Sputum Viscosity
 Bloody Gelatinous Sputum (Currant-Jelly)

 Klebsiella Pneumonia
 Pneumococcal Pneumonia
 Stringy Mucoid Sputum (may also appear frothy)

 Follows Asthma exacerbation

 Cloudy, mucoid Sputum

 Chronic Bronchitis
 Three layered appearance (stagnant, Purulent Sputum)

 Bronchiectasis
 Lung Abscess
Sputum with Feculent Odor

 Anaerobic infection
 Bronchiectasis
Sputum examination

 Tests
 Gram Stain
 ZN, Kinyoun, Auramine ( M. tuberculosis)
 Culture
 PAS staining or Methenamine silver staining (Fungal)

 Efficacy of Sputum exam

 Sputum has low diagnostic yield in CAP
 Not recommended in community acquired
pneumonia
Sputum Microscopy
Assessing Sputum Sample Quality

 Ideal Sputum Sample for Culture

 Under 10 squamous epithelial cell per

low power field
 Many Neutrophils present (>5 per high
power field)
 Bronchial epithelial cells present
 Alveolar Macrophages may be present
 Inadequate Sputum Sample

 Over 25 squamous epithelial cells/LPM

Elements Present in Sputum

 Cellular elements
 Non-cellular elements
Cellular Elements of Sputum

 Squamous epithelial cells

 Respiratory epithelial cells
 Polymorphonuclear leukocytes
 Mononuclear cells
 Alveolar macrophages
 Characteristics of

Squamous Epithelial
Large, flat, plate-like cells
 Cells
Copious clear or ground glass cytoplasm
 Relatively small dense nucleus, frequently located
eccentrically
 Sharp and clear cut cellular boundaries with straight edges
which give the cell a polygonal appearance
 Part of the cytoplasm may be folded back on itself
 Cells are often covered with many bacteria
Squamous epithelial cells are easily seen and recognized
under low power magnification.
The lining cells of the oropharynx, their presence in a
sputum smear usually indicates contamination with
saliva.
Characteristics of
Respiratory Epithelial Cells

 Long slender cells

 Cilia at one end of the cell
 Cilia supported by basal plate
 Nucleus located at base of cell
 Slender "tail" at opposite end to cilia
 Respiratory Epithelial Cells

Respiratory epithelial cells are columnar epithelial cells

which are often ciliated. The cilia are supported by a darkly
staining basal plate. The nucleus is usually located at the
base of the cell near the tail. Epithelial cells are found in
many parts of the upper respiratory tract. They line the
bronchial tree and they are frequently seen in specimens
which have been obtained mechanically, such as
bronchoscopy specimens and transtracheal aspirations.
They can also be found in the nasal passages so that their
presence is not proof of a good sputum specimen.
Respiratory Epithelial Cells
 Polymorphonuclear Leukocytes

 Polymorphonuclear leukocytes are commonly known as

polys or pus cells.
 The cells examined up to this point are normal residents
of the respiratory tract.
 The poly migrates into an area in response to an
inflammatory stimulus and is seen in the respiratory tract
only as a result of an acute inflammatory process.
 Frequently ,the inflammatory process is caused by
bacterial infection.
 Large numbers of polys are usually present during an
acute inflammatory reaction.
Characteristics of
Polymorphonuclar Leukocytes

 Multi-lobed nuclei
 Granular cytoplasm
 Cytoplasm sometimes contains
phagocytosed bacteria
At high power the intact poly is easily identified by its multi-lobed nucleus and
granular cytoplasm.
Degenerating cells are often present. The cell walls of these cells are disrupted and the cytoplasm
leaks out. The nuclei usually remain intact and the identity of the cel1 can be established from this.
 Mononuclear Cells

 A variety of small cells with single lobed nuclei may be

present in sputum specimens.

 The Gram stain is not suitable for separating the

different types and they are therefore all grouped
together as mononuclear cells.

 Lymphocytes are the most significant members of this

group.

 Their presence is an indication of a chronic

inflammatory process, a viral infection, or certain
bacterial infections.
Under high power, any cell with a single nucleus that cannot be identified as an epithelial cell or an alveolar macrophage is
classified as a mononuclear cell.
Non-cellular Elements

 Mucus threads
 Curschmann’s spirals
 Bacteria
 Yeasts
Mucus

 Important part of the normal defense mechanism of

the lungs
 Produced by goblet cells which line the bronchi
 Spreads in a thin, even layer over the tissue surfaces
 Provides a transport system for the removal of foreign
bodies from the respiratory tract
 In many disease states, an excess of mucus is
produced and is expectorated
 Cells and bacteria become enmeshed in the mucus
and it is this combination of material that is known as
sputum
Mucus
 Bacteria

 The etiology of bacterial infections cannot be

diagnosed solely by the Gram stain morphology of
the organisms in a direct smear.

 However, the morphology of some organisms is

sufficiently characteristic that a tentative diagnosis
can be made on the basis of the smear .

 In sputum smears the most common organisms to fall

into this category are Streptococcus pneumoniae,
staphylococci, Hemophilus influenzae, members of
the family Enterobacteriaceae and some
pseudomonads.
Staphylococcus aureus
Streptococcus pneumoniae