Specimen collection: respiratory tract

secretion sampling
Defi nition

Obtaining a specimen from the respiratory tract is important in diagnosing

illness, infections and conditions such as tuberculosis and
lung cancer (Guest 2008 ). A sample can be obtained invasively or
non-invasively and the correct technique will enable a representative
sample to identify respiratory tract pathology and to guide treatment.

Related theory

Excessive respiratory secretions may be due to increased mucus

production in cases of infection, impaired mucociliary transport
or a weak cough refl ex (Hess 2002 ). Lower airway secretions that
are not cleared provide an ideal medium for bacterial growth. Suitable
microbiological analysis in diagnosing infection will depend
upon (HPA 2014k ):
the adequacy of lower respiratory tract specimens
avoidance of contamination by upper respiratory tract and oral
fl ora
use of microscopic techniques and culture methods
current and recent antimicrobial therapy.

Evidence-based approaches
Rationale

The main aim of sputum/secretion collection is to provide reliable

information on the causative agent of bacterial, viral or fungal
infection within the respiratory tract and its susceptibility to
antibiotics for guiding treatment (Ioanas et al. 2001 ).

Indications

A respiratory tract secretion specimen is indicated:

when there are clinical signs and symptoms of a respiratory
tract infection, such as a productive cough, particularly with
purulent secretions
if there are signs of systemic infection or in patients with a PUO
of >38C (Perry 2007 ).
The presence of sputum, especially when discoloured, is commonly
interpreted to represent the presence of bacterial infection
and as an indication for antibiotic therapy. However, purulence
primarily occurs when infl ammatory cells or sloughed mucosal
epithelial cells are present, and can result from either viral or bacterial
infection (Johnson et al. 2008 ). One strategy for limiting or
targeting antimicrobial prescribing is to send a respiratory tract
specimen for microbiological analysis to either demonstrate that
a substantial infection is not present or to identify an organism for
which antimicrobial treatment is deemed necessary.
The accuracy of microbiological analysis can depend on the
quality of the specimen obtained as well as the time taken for
transportation and the method by which it is stored and transported
(Perry 2007 ).

Methods of non-invasive and semi-invasive sampling

A suffi cient quality of sputum will yield a representative sample

and early morning sputum samples are preferred as they contain
pooled overnight secretions in which pathogenic bacteria are
more likely to be concentrated (Philomina 2009 ).

Obtaining a sputum sample

Sputum is a combination of mucus, infl ammatory and epithelial

cells, and degradation products from the lower respiratory tract
(Dulak 2005 ). It is never free from organisms since material originating
from the lower respiratory tract has to pass through the
pharynx and the mouth, which have commensal populations of
bacteria (Thomson 2002 ). However, it is important to ensure that
material sent to the microbiology laboratory is of sputum rather
than a saliva sample, which will contain squamous epithelial cells
and be unrepresentative of the underlying pulmonary pathology.
Sputum produced as a result of infection is usually purulent
and a good sample can yield a high bacterial load (Weston 2008 ).

For patients who are self-ventilating, co-operative, able to cough,

expectorate and follow commands, a sputum sample is a suitable
collection method. In cases of suspected Mycobacterium tuberculosis
, three sputum specimens are required as the release of the
organism is intermittent, before the pathogenic organisms can be
isolated (Damani 2012 ). See Figure 10.1 and Procedure guideline
10.29: Sputum sampling.

Nasopharyngeal samples

Nasopharyngeal suctioning is a viable alternative for patients who

are obtunded or whose cough is weak (Dulak 2005 ). Sampling techniques
to obtain specimens from the nasopharynx are semi-invasive
but can be used on patients who are self-ventilating. They are indicated
in suspected viral infections such as respiratory syncytial
virus (RSV), infl uenza and parainfl uenza. The main aim is to collect
epithelial cells from the posterior nasopharynx and a sample can be
obtained using nasal washing or vacuum-assisted aspiration (see
Procedure guideline 10.30: Nasopharyngeal wash: syringe method).
This method can yield a more reliable sample because the normal
fl ora present in the oropharynx are bypassed (Philomina 2009 ).

Invasive sampling techniques

Intubated patients who are unable to clear secretions independently

or who require more accurate specimen collection may need
a more invasive technique to obtain a sample. Invasive techniques
obtain secretions directly from the lower airway and are designed
to avoid contamination by upper airway colonization, which may
lead to misinterpretation of cultures (Ioanas et al. 2001 ).

Vacuum-assisted aspirate via endotracheal tube

Endotracheal suctioning is frequently used as a diagnostic method

and for obtaining specimens in intubated patients with suspected
pulmonary infection. This technique bypasses the upper respiratory
airways and provides an accurate microbiological result.
Suctioning aids the clearance of secretions by the application of
negative pressure through a sterile fl exible suction catheter or a
closed suction system. A sterile sputum trap is attached to the
suction catheter at one end, whilst the other end is attached to the
suction tubing to collect the sample (Figure 10.13 ).

Bronchoalveolar lavage (BAL)

Bronchoalveolar lavage is a reliable and accurate technique that

provides a good diagnostic yield in cases of pulmonary infection,