2/25/2013

SPUTUM
Miscellaneous Body Fluids: Sputum, Sweat, Gastric Fluid
Secretion of the goblet cells (lining the respiratory tract) No goblet cells in the alveoli DUST CELLS o Hallmark of sputum o Macrophages with carbon deposits

Erika Gayle M. Lipana, RMT

SPUTUM: How to induce release?

1. 2. 3. 4. Use of nebulized saline or distilled water Chest percussion Postural drainage Aerosolized 15% NaCl and 10% glycerin

SPUTUM: Preservation
1. Refrigeration 2. Use of 10% formaldehyde (cannot be used for bacteriologic purpose because of its bacteriostatic effect)

SPUTUM COLLECTION
FIRST MORNING SPECIMEN is the BEST!
1. 2. 3.

SPUTUM COLLECTION: Obtaining a sputum sample

Mouth should be free from foreign objects
Remove food. Gum or tobacco Remove dentures Gargle prior to collection

Patient should be instructed to cough up the sputum which is then Early morning specimen is collected in clean, sterile, the best wide mouth bottle or Induce sputum if necessary disposable plastic 1. Nebulized hypertonic saline or distilled containers. NEVER USE water PAPER CUPS! 2. Chest percussion Cough into sterile cup
3. Postural damage

Erika Gayle M. Lipana, RMT

2/25/2013

SPECIMEN COLLECTION: Special Circumstances

Tuberculosis is suspected
1. Sputum collected in negative pressure room 2. Early morning gastric aspirate 3. Bronchoscopy with bronchial lavage 4. 3 day successive collection (morning sample only)

Anaerobic culture specimen

SPECIMEN COLLECTION: Special Circumstances

Viral culture specimens

1. Tracheal aspiration 2. Thoracentesis (insertion of a hollow needle into the pleural cavity through the chest wall in order to withdraw fluid, blood pus, or air) 3. Direct lung puncture

1. Patient gargles and expectorates with nutrient broth 2. Nasopharyngeal swab transported in viral medium

SPECIMEN COLLECTION: Preparation of sputum for laboratory examination

Fixation of sputum for cytology (prevents air drying) Culture specimen transport to laboratory
1. 2. 1. 2. Patient expectorates into a jar of 70% ethanol Spread fresh sputum on slide and spray paps fixative

SPUTUM: Physical Characteristic

Sputum gram stain assesses the sample for adequacy. Anaerobic culture transported in an air tight container (should be immediately for immediate plating) I. Bring to laboratory as quickly as possible II. Refrigerate sample if transport is delayed III. Consider washing specimen of oral flora i. Rinse several times with saline ii. Discard supernatant (non-viscous saliva) 3. Aerobic culture specimen 4. Tuberculosis culture (maybe stored at room temperature for up to 48 hours)

QUANTITY

o Very few in amount or NOTHING AT ALL!

SPUTUM: Physical Characteristic

CONSISTENCY
o Watery (sialic acid is responsible for sputums viscosity) o Blood-gelatinous sputum (CurrantJelly) Klebsiella pneumoniae infection Pneumococcal pneumonia o Stringy Mucoid Sputum (may also appear frothy) Follows asthma exacerbation o Cloudy, mucoid sputum Chronic bronchitis o Three layered appearance (stagnant, purulent sputum) Bronchiectasis Lung abscess

Reaction

SPUTUM: Physical Characteristic

Turbidity

o Slightly acidic o pH 6.5-7.0 o Frothy sputum or serous (air bubble, hemoglobin) Pulmonary eddema o Mucoid Bronchiectasis TB with cavities o Foamy, clear materials Saliva Nasal secretions

Erika Gayle M. Lipana, RMT

2/25/2013

Odor

SPUTUM: Physical Characteristic

o Normally: ODORLESS o Abnormally: Sweetish o In pulmonary tuberculosis with cavities, bronchiectasis, bronchomoniliasis Putrid or foul o Usually due to Fusobacteria & Spirochetes found in mouth, or anaerobic infections within the lung, lung abscess and necrotizing bronchogenic carcinoma Cheesy odor o In necrosis or malignant tumors and perforating emphysema Fecal Odor o Rupture sunphrenic or liver abscess and in enteric gram negative products.

COLOR Normally, the color is greatly influenced by pus, as well as nature of the disease and the sputum itself.

SPUTUM: Physical Characteristic

o Colorless or transluscent or opaque When made of mucus only o White or yellow When pus is present, seen in advance pulmonary tuberculosis, chronic bronchitis, jaundice and lobar pneumonia o Gray When pus and epithelial cells are present o Bright green or greenish When bile is present as in jaundice, rupture of the liver abscess into the lungs and infection caused by

Pseudomonas aeruginosa

COLOR

SPUTUM: Physical Characteristic

o Red or bright red When there is fresh blood or new hemorrhage. If blood streaks are present, it is indicative of pulmonary tuberculosis or bronchiectasis o Anchovy sauce or rusty brown When old blood is present, seen in pneumonia, pulmonary gangrene, rupture of amoebic abscess of the liver into the lung or pigmented cells in chronic passive congestion, due to cardiac pigment after hemorrhage from the lung pulmonary infarction. o Prune-juice Pneumonia and chronic cancer of the lungs o Rusty red Lobar pneumonia

COLOR

SPUTUM: Physical Characteristic

o Olive green or grass green Cancer o Black Indicates inhalation of dust or dirt, carbon, charcoal, in cases like anthracosis and heavy smokers. o Yellow green Due to destruction of neutrophils and release of verdo peroxidase

Cheesy masses

SPUTUM: Macroscopic Structures

SPUTUM: Macroscopic Structures

Curschmanns spiral

o Fragments of necrotic tissue, pulmonary tissue or bits cartilaginous rings, from pinpoint to pin size. o Present in so-called nummular sputum from a tuberculosis cavity, pulmonary gangrene, abscess of the lungs and actinomyccosis. o Seen in bronchial asthma o Yellowish-white, spirally twisted mucoid strands

Bronchial cast

Dittrichs bodies

o These are branching tree-like casts of the bronci, seen in lobar pneumonia, fibrinous bronchitis and diphtheria o Yellow of gray caseous masses, seen in asthma, putrid bronchitis o Pinhead o Emits a foul odor when crushed

Erika Gayle M. Lipana, RMT

2/25/2013

SPUTUM: Macroscopic Structures

Lung stone
o Bronchioliths or pneumoliths o Small calcified nodules or stagnant contents of cavities or dilated bronchi or calcified tuberculosis tissue. Sometimes the core is a small foreign body or a fungal growth. o Include concretions formed in the bronchi made of calcium carbonate and phosphate and aspirated substances such as: pollen, seeds, dust o Echinococcus granulosus, Toxaplasma

SPUTUM: Microscopic Examination

Must be treated first with KOH or NaOH to dissolve the mucus. Elastic fibers

Foreign bodies

Curschmanns spiral

o Normally present in the walls of the alveoli, bronchioles and the blood vessels o Yellow, wavy threads o Usually coiled into balls, seen in bright colorless wit central lines.

Parasites

canis, paragonimus westermanii

Crystals

SPUTUM: Microscopic Examination

SPUTUM: Microscopic Examination

o Indicates stasis and decomposition of the sputum in the body or in a n old specimen that is often unsatisfactory Charcot Leyden crystals o Seen in bronchial asthma, arises from the disintegration of eosinophil o Stains black in hematoxylin and red with eosin o Often octahedral and/or hexagonal in shape Hematoidin o Rhombic and brownish red o Arranged in rosettes o Resulted down from breaking down of old blood and are found in pulmonary infections, lung abscess, pulmonary infarction

Crystals

SPUTUM: Microscopic Examination

SPUTUM: Microscopic Examination

Heart failure cell
o Blood pigmented cells, chiefly hemosiderin o Appears as round grayish or colorless o Diffuse staining o Found in congestive heart failure o Contain carbon and are less important o Appears as angular black granules both intracellular and extracellular o Seen in anthracosis, heavy tobacco smokers and in people living in smoky atmosphere

o Cholesterol crystals Colorless, thin, rhombic plates with notched corner. This indicates stasis with fatty degeneration of exudates and are often in lung abscess and emphysema o Fatty acid crystal Long, colorless needles, arranged in seeves. Also indicates stasis with fatty degeneration of exudates and are often in lung abscess and emphysema

Carbon-Laden crystals

Erika Gayle M. Lipana, RMT

2/25/2013

SPUTUM: Microscopic Examination

Myelin globules
o With little or no clinical significance o Colorless, round, oval or ear-shaped globules of various sizes

Actinomyces hominis

SPUTUM: Microscopic Examination

o Reported in order to minimize confusions with more important structures like Blastomyces. o Resembles fat droplets and yeast-like fungi o Large structures show peculiar concentric or irregular spiral markings o Abundant in the scanty morning sputum of health persons and may be found in closely packed sputum o Absent or scarce in specimens with inflammatory exudates.

o Small and yellowish structures with sulphur granules which can be seen with unaided eye o Similar structure with Actinomyces bovis under LPO o consist of a network of threads having more or less radial arrangement o Seen better by running small amount of eosin in alcohol solution and glycerin under the cover glass o Seen in Actinomycotic pulmonary infection

SPUTUM: Microscopic Examination

Moulds and yeasts

o Hyphae are rods usually jointed or branched and often arranged in meshwork (mycelium) o Spores are highly refractive spheres and ovoid o Seen in pneumomycosis specifically infection by o Grows in standing specimen

Blood Cells

SPUTUM: Microscopic Examination

Aspergillus fumigatus

sputum upon long of tuberculosis

o Leukocyte Major blood present in sputum Markedly increased when pus is present Eosinophil are commonly seen in allergic patients (asthma) and can be demonstrated by Wrights stain o Erythrocytes Present in lung hemorrhage, pulmonary tuberculosis, and infection Detected by Guaiac or benzidine tests or presence of blood derivatives such as hemosiderin

Creola Bodies

Paragonimus

westermanii

o Cluster of ciliated columnar cells found in the sputum of asthmatic patients.

The common eccrine glands function in the regulation of the body temperature. They are innervated by cholinergic nerve and are a type of exocrine gland. Sweat has been analyzed for its multiple inorganic and organic contents, but with one notable exception, has not proven a clinically useful model. The exception is the analysis of sweat for chloride and sodium levels in the diagnosis of CYSTIC FIBROSIS

SWEAT

CYSTIC FIBROSIS
Also known as mucoviscidosis An autosomal, recessive inherited disease that affects the exocrine glands and causes electrolyte and mucous abnormalities

Erika Gayle M. Lipana, RMT

2/25/2013

CYSTIC FIBROSIS
Principle:

Methods/ Diagnosis
Pilocarpine NitrateIontophoresis by Gibson and Cooke

Pilocarpine is introduced into skin by iontophoresis to stimulate locally increased sweat gland secretion. The resulting sweat is absorbed by filter paper or gauze, diluted with water and analyzed for sodium and chloride determination

METHODS/ DIAGNOSIS: Pilocarpine NitrateIontophoresis by Gibson and Cooke Site of Iontophoresis

Methods/ Diagnosis
Gauze pad Macro duct collection COLOR
o Place a weighed gauze pad on patients back overnight, that pad is sealed tightly to prevent evaporation and removed in the morning. The pad is then weighed, diluted with water and analyzed for sodium and chloride

o Sweat should only be collected from the arms or legs o The area for stimulation must be free from skin lesion o The skin should be cleaned with distilled water, washed followed by drying with paper tissue

Brown Red Blue Blue-black

Ochronosis Rifampin overdose Occupation exposure to copper Idiopathic Chronhidrosis

Sodium
It should approximate the chloride concentration, so it is measured to provide better quality control
* Discrepancies for sodium and chloride is influenced by air bubbles (decrease concentration) and temperature fluctuations

Electrolytes
Use the osmometer method for measuring sweat electrolytes provides a means for evaluation of young infants without subjecting them to the Rigos traditional sweat collection method The test should be performed on infants older than 8 days because newborn infants consistently have high electrolyte concentrations Because the sweat osmolarity is measured on an undiluted sample, cre must be taken to include the water that condences on the plastic cover or values will be falsely elevated

Erika Gayle M. Lipana, RMT

2/25/2013

Electrolytes
Reference Ranges:

Test for Sweat Chloride AgNO3 Method Cotlove Chloridometer

Electrolytes

Normal Abnormal Equivocal

SODIUM < 70 mEq/L > 90 mEq/L 70-90 mEq/L

CHLORIDE < 50 mEq/L > 60 mEq/L 50-60 mEq/L

Test Results: Adults generally have higher sodium and chloride concentrations in their sweat than children. Also, sweat test results in adults can vary widely. This is especially true in women, because the amount of salt in their sweat can vary with the phase of their menstrual cycle. Enough sweat must be collected to get accurate results.

Normal values may vary from lab to lab. Sweat chloride must be measured to diagnose cystic fibrosis. Some labs also measure sodium. Normal and abnormal sweat sodium values vary slightly from sweat chloride values.

Composition: 99% H2O, 1% solid 0.2-0.4% HCl

GASTRIC JUICE

Composition: Electrolytes Mucin

GASTRIC JUICE

Digestive enzymes

o production by the parietal cells (oxyntic cells); for the activation of Pepsinogen Gastrin o Hormone stimulating secretion of HCl Zollinger-Ellison o High secretion of gastrin due to gastrin-secreting tumor oxygenating from the pancreas o Produced by the chief cells (Zymogen or peptic cells) Pepsin (protein) Lipase (fats) Rennin (to curdle milk)

o H+ (1 million times greater than blood) o Na, Cl, Mg, Ca, Fe o From the goblet or mucous cells to prevent autodigestion of the stomach o For the absorption of Vitamin B12 to prevent Pernicious Anemia

Intrinsic factor of Castle

Collection

o Intubation (fasting patient) o Ewalds or Boas Method (best evacuated tube)

Pentagastrin
o o o o o

GASTRIC JUICE: Commonly Used Stimulants

Gastric Juice: Physical Characteristics

Quantity Color Odor Reaction Specific Gravity Consistency Mucus Sediment 20-50 mL Grayish or bile-stained; colorless Sloightly sour or odorless Acidic (pH 1.6-1.8) 1.001- 1.010 Watery Small amount Normally non

Histalog

Stimulant of choice Synthetic compound resembling gastrin Produce more rapid response No discomfort Specimens are collected at 15 minutes interval for 1 hour following the administration

Histamine TUBELESS METHOD

o When used, collection must continue for 2 hours because maximum output is delayed

o Diagnex blue test o Patient is given an Azure A dye

Erika Gayle M. Lipana, RMT

2/25/2013

1 acidity = 0.00365% HCl Free HCl

o 25-50 or 20-40 mEq/L o Tests: Topfers Boas Gunzberg

Gastric Juice: Chemical Characteristics

Combined HCl (Acid-metaprotein)

Gastric Juice: Chemical Characteristics

Lactic acid

o N.V. = 10-15 o Composed of HCl which combines loosely with the protein in the absence of free HCl o Normally absent o Indicates advanced gastric cancer o Maybe found in the stomach from the fermentation of CHO or from the production of lactic acid-forming bacteria like Boas-oppler bacilli o Normally none o Seen in peptic ulcers and gastric carcinoma

Total acidity

o 50-75 o Composed of free HCl, combined HCl, acid salts and organic acids like lactic acid, butyric acid and amino acids o Tests: Topfers Phenolpthalein

Occult blood

Bile

Gastric Juice: Chemical Characteristics

Definition of Terms
Euchlorhydria Hyperchlorhydria Hypochlorhydria Achlorhydria
o Normal acidity o Increased free HCl around 60 o Seen in: Peptic ulcers like duodenal and gastric ulcers o Decreased free HCl o Seen in: Gastric syphilis, Gastric cancer, Chronic gastritis o Absence of free HCl o Seen in: Pernicious Anemia, Gastric cancer, pellagra o Absence of HCl and renin in gastric juice o Inability to produce a pH less than 6.0 following gastric stimulation

Renin

o Small amount o Absence indicates organic disease o Tests: Reitman Riegel

Pepsin

o Absence indicates organic disease o Tests: Bauer Hammerschlag

Achylia gastrica

Anacidity

Erika Gayle M. Lipana, RMT