The main methods of The main methods of functional diagnostics functional diagnostics of pulmonary diseasesof pulmonary diseases

Obtaining a sputum Obtaining a sputum samplesample

Mouth should be free of foreign objects Mouth should be free of foreign objects Remove food, gum, or Remove food, gum, or TobaccoTobacco Remove dentures Remove dentures

Early morning specimen is best Early morning specimen is best Induce sputum if necessary Induce sputum if necessary

Nebulized hypertonic saline or Nebulized hypertonic saline or distilled water distilled water

Chest percussion Chest percussion Postural drainage Postural drainage

CoughCough into sterile specimen cup into sterile specimen cup

Special Circumstances Special Circumstances TuberculosisTuberculosis suspected suspected

Sputum collected in negative pressure room Sputum collected in negative pressure room Early morning gastric aspirate Early morning gastric aspirate Bronchoscopy with bronchial lavage Bronchoscopy with bronchial lavage

Anaerobic culture specimen Anaerobic culture specimen Transtracheal aspiration Transtracheal aspiration ThoracentesisThoracentesis Direct lung puncture Direct lung puncture

Viral Culture Specimens Viral Culture Specimens Patient gargles and expectorates with Patient gargles and expectorates with

nutrient broth nutrient broth Nasopharyngeal swab transported in viral Nasopharyngeal swab transported in viral

medium medium

Preparation of Sputum for Preparation of Sputum for Lab Lab

Fixation of sputum for cytology (prevents air drying) Fixation of sputum for cytology (prevents air drying) Patient expectorates into jar of 70% Patient expectorates into jar of 70% EthanolEthanol Spread fresh sputum on slide and spray pap fixative Spread fresh sputum on slide and spray pap fixative

Culture specimen transport to lab Culture specimen transport to lab Sputum Gram StainSputum Gram Stain assesses sample for adequacy assesses sample for adequacy Anaerobic cultures transported in air tight container Anaerobic cultures transported in air tight container

Transport to lab for immediate plating Transport to lab for immediate plating Aerobic culture specimen Aerobic culture specimen

Bring to lab as quickly as possible Bring to lab as quickly as possible Refrigerate specimen if transport delayed Refrigerate specimen if transport delayed Consider washing specimen of oral flora Consider washing specimen of oral flora

Rinse several times with saline Rinse several times with saline Discard supernatant (non-viscous Discard supernatant (non-viscous SalivaSaliva) )

TuberculosisTuberculosis culture culture May be stored at room temperature for up to 48 May be stored at room temperature for up to 48

hour hour

Sputum Gross ExamSputum Gross Exam

Estimate daily volume of Estimate daily volume of SputumSputum

Small amounts Small amounts Lung AbscessLung Abscess PneumoniaPneumonia TuberculosisTuberculosis

Copious amounts (>200 cc/day) Copious amounts (>200 cc/day) BronchiectasisBronchiectasis Bronchopleural FistulaBronchopleural Fistula

Sputum Color Sputum Color

Bloody SputumBloody Sputum ( (HemoptysisHemoptysis) ) Rusty Rusty SputumSputum (Prune-juice) (Prune-juice)

Pneumococcal PneumoniaPneumococcal Pneumonia Purulent SputumPurulent Sputum (yellow, green, (yellow, green,

dirty-gray) dirty-gray) Color alone does not Color alone does not

distinguish bacterial distinguish bacterial infection infection

Sputum TurbiditySputum Turbidity

Frothy Frothy SputumSputum (air bubbles, (air bubbles, HemoglobinHemoglobin) ) Pulmonary edema Pulmonary edema

Foamy, clear material Foamy, clear material SalivaSaliva Nasal secretions Nasal secretions

Sputum Viscosity Sputum Viscosity Bloody Gelatinous Bloody Gelatinous SputumSputum (Currant-Jelly) (Currant-Jelly)

KlebsiellaKlebsiella PneumoniaPneumonia Pneumococcal PneumoniaPneumococcal Pneumonia

Stringy Mucoid Stringy Mucoid SputumSputum (may also appear (may also appear frothy) frothy)

Follows Follows AsthmaAsthma exacerbation exacerbation Cloudy, mucoid Cloudy, mucoid SputumSputum

Chronic BronchitisChronic Bronchitis Three layered appearance (stagnant, Three layered appearance (stagnant,

Purulent SputumPurulent Sputum) ) BronchiectasisBronchiectasis Lung AbscessLung Abscess

Sputum with Feculent Sputum with Feculent OdorOdor

Anaerobic infection Anaerobic infection BronchiectasisBronchiectasis

Sputum Sputum MicroscopyMicroscopy

Assessing Sputum Sample Assessing Sputum Sample QualityQuality

Ideal Ideal SputumSputum Sample for Culture Sample for Culture Under 10 squamous epithelial cell Under 10 squamous epithelial cell

per low power field per low power field Many Many NeutrophilNeutrophils present (>5 per s present (>5 per

high power field) high power field) Bronchial epithelial cells present Bronchial epithelial cells present Alveolar Alveolar MacrophageMacrophages may be present s may be present

Inadequate Inadequate SputumSputum Sample Sample Over 25 squamous epithelial Over 25 squamous epithelial

cells/LPM cells/LPM

Sputum Sample Sputum Sample Preparation Preparation

Pull strand or plug of Pull strand or plug of SputumSputum onto slide onto slide

Consider buffered crystal Consider buffered crystal violet to stain cells violet to stain cells

Apply cover slip Apply cover slip View under oil immersion View under oil immersion

Cytology Stains Cytology Stains No Stain No Stain

BlastomycosisBlastomycosis Cryptococcosis Cryptococcosis

Gram StainGram Stain Gram Positive BacteriaGram Positive Bacteria Candida Candida TuberculosisTuberculosis (weakly (weakly Gram PositiveGram Positive) ) NocardiaNocardia (weakly (weakly Gram PositiveGram Positive) )

Direct Fluorescent Direct Fluorescent AntibodyAntibody Staining Staining LegionellaLegionella

Wright stain or Giemsa Stain Wright stain or Giemsa Stain Intracellular organisms Intracellular organisms

Special Staining Special Staining Circumstances Circumstances

Acid-fast Mycobacteria Acid-fast Mycobacteria (Tuberculosis)(Tuberculosis)

Ziehl-Neelsen Stain (Red against blue Ziehl-Neelsen Stain (Red against blue background) background)

Kinyoun stain Kinyoun stain Less reliable than Ziehl-Neelsen stain Less reliable than Ziehl-Neelsen stain Results in quickly stained sample Results in quickly stained sample

Fluorochrome dyes (auramine, Fluorochrome dyes (auramine, rhodamine) rhodamine) Higher false positive rate than Ziehl-Higher false positive rate than Ziehl-

Neelsen stain Neelsen stain Assist greatly in identifying organisms Assist greatly in identifying organisms

Fungal OrganismsFungal Organisms

PAS staining or Methenamine PAS staining or Methenamine silver staining silver staining HistoplasmosisHistoplasmosis CoccidioidomycosisCoccidioidomycosis AspergillusAspergillus Mucor Mucor

KOH PreparationKOH Preparation

Microscopic findings Microscopic findings Caseous masses Caseous masses Dittrich's plugs Dittrich's plugs Curschmann's spirals (Curschmann's spirals (AsthmaAsthma) ) Charcot-Leyden Crystals (Charcot-Leyden Crystals (AsthmaAsthma) ) Bronchial casts Bronchial casts Concretions Concretions Broncholith Broncholith

Calcified particles as seen in Calcified particles as seen in BroncholithiasisBroncholithiasis Lung CancerLung Cancer cells cells

Central bronchus tumors Central bronchus tumors May require 4 samples to detect May require 4 samples to detect

EosinophilEosinophils (>5%): identified with Wright's Stain s (>5%): identified with Wright's Stain Allergy Allergy AsthmaAsthma

PneumoniaPneumonia

General General Lab Indications Lab Indications

Moderate or severe community Moderate or severe community acquired pneumonia acquired pneumonia

Patient with comorbid Patient with comorbid conditions conditions

Efficacy of Labs Efficacy of Labs No value in non-severe No value in non-severe

community acquired pneumonia community acquired pneumonia

SputumSputum Examination Examination

Tests Tests Sputum Gram StainSputum Gram Stain Sputum CultureSputum Culture

Efficacy of Efficacy of SputumSputum exam exam SputumSputum has low diagnostic has low diagnostic

yield in CAP yield in CAP Not recommended in Not recommended in

community acquired community acquired pneumonia pneumonia

Blood CultureBlood Culture

Indications Indications Not indicated unless severe Not indicated unless severe

disease disease Recommended by ATS in Recommended by ATS in

hospitalized CAP hospitalized CAP Efficacy Efficacy

Low sensitivity: Positive in Low sensitivity: Positive in only 5-10% of cases only 5-10% of cases

Does not predict severity or Does not predict severity or outcome outcome

Specific Testing with Specific Testing with reasonable efficacyreasonable efficacy

ChlamydiaChlamydia pneumonia pneumonia Rapid PCR (>30% Rapid PCR (>30% Test SensitivityTest Sensitivity) )

InfluenzaInfluenza Rapid Influenza TestRapid Influenza Test ( (InfluenzaInfluenza DFA) DFA)

Legionella pneumophilaLegionella pneumophila Rapid PCR of Rapid PCR of SputumSputum (80% (80%

Test SensitivityTest Sensitivity) ) Urinary antigen (>50% Urinary antigen (>50% Test SensitivityTest Sensitivity) )

Mycoplasma pneumoniaeMycoplasma pneumoniae Rapid PCR of Rapid PCR of SputumSputum (>30% (>30%

Test SensitivityTest Sensitivity) )

Chronic BronchitisChronic Bronchitis

Labs Labs Arterial Blood GasArterial Blood Gas (ABG) (ABG)

Markedly reduced arterial pO2 Markedly reduced arterial pO2 Elevated arterial pCO2 (40-50 mmHg) Elevated arterial pCO2 (40-50 mmHg)

Pulmonary Function TestPulmonary Function Tests s Residual VolumeResidual Volume increased increased FEV1 decreased FEV1 decreased FEV1/FVC decreased FEV1/FVC decreased FEF 25-75 (mid-flows) decreased FEF 25-75 (mid-flows) decreased Diffusion capacity (Diffusion capacity (DLCODLCO) near normal ) near normal

Bronchiectasis Bronchiectasis

Labs: Sputum Labs: Sputum SputumSputum forms layers on standing forms layers on standing

Top: Mucus Top: Mucus Middle: Clear fluid Middle: Clear fluid Bottom: Pus Bottom: Pus

Sputum Culture not diagnostic Sputum Culture not diagnostic (mixture of organisms) (mixture of organisms)

Fungal Culture Fungal Culture

Lung AbscessLung Abscess

Labs Labs Sputum examination Sputum examination

Microscopy Microscopy Gram Stain Gram Stain Mycobacterial stains Mycobacterial stains Fungal stains Fungal stains

Sputum layers on standing Sputum layers on standing Sputum Cultures are usually not Sputum Cultures are usually not helpful helpful

Complete Blood Count Complete Blood Count Leukocytosis Leukocytosis

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