putum quality: Can you tell

by looking?
D. J, ~lo~rnoy, PhW b
L. J. Davidson, RN, MN
Oklahoma City, Oklahoma

Background: Nurses are responsible for the collection of sputum samples for culture in
most institutions, yet they receive little formal training on what a good specimen looks
like.
Methods: Three hundred thirty-three consecutively collected expectorated sputum
samples and tracheal aspirates were examined to determine the relationship of
macroscopic specimen appearance (watery, mucoid, mucopurulent) to specimen quality
(good, fair, poor).
Results: Of the expectorated sputum samples, 21% were watery, 65% were mucoid, and
I4% were mucopurulent. Sixty-five percent of the expectorated sputum samples were
good or fair, regardless of appearance. Eighty-seven percent of mucopurulent
expectorated sputum samples were good or fair. In the remaining nonmucopurulent
specimens, however, there were no predictable markers of specimen quality.
Conclusions: The only specimens that were predictably good were those that were
mucopurulent yellow, yellow, or tracheal aspirates. (AJIC AM J INFECT CONTROL
1993;21:64-9)

Nurses often are responsible for obtaining spu- may therefore take 1 to 3 days from collection to
tum cultures from patients. The quality of these report.
specimens varies, because samples are easily If a poor specimen could be distinguished
contaminated with oropharyngeal materials dur- macroscopically (at the bedside), other options
ing expectoration. Indeed, specimens with heavy (induction of sputum, transtracheal aspiration,
oropharyngeal contamination account for as bronchoscopy, etc.) could be explored earlier in
many as 57% of all those submitted for culture. 2 the course of the disease. The early i
The information obtained from cultures therefore of inadequate and poor (Table I) specimens would
also varies considerably. undoubtedly save valuable time in determining the
The length of time between sputum collection, origin of lower respiratory tract infection. The
specimen evaluation by Gram stain, or completion possibility of reducing the amount of time spent on
of culture can be critical. In our hospital for testing poor specimens prompted us to explore the
specimens collected in the morning, Gram stains relationship between sputum appearance and
are usually performed within several hours after quality. Macroscopic, physical factors in sputum
specimens reach the laboratory. If the specimen is were examined to determine the quality of the
adequate (good, fair, or poor), a culture is set up specimen.
and interpreted the next morning. If potential The grading of sputum specimens (for routine
pathogens are seen, identification tests and anti- bacterial culture) by Gram stain became popular
microbial susceptibilities are set up; they require after Bartletts classic 1974 book on relevance in
at least another day to complete. A sputum culture clinical microbiology.3 Bartlett recomme~
Gram stain as a means of grading sputum ade-
From the Laboratory Service, Veterans Affairs Medical Center,a quacy, on the basis of presence of squamous
Department of Pathology,b and College of Nursing,C University of epithelial cells (representing oropharyngeal con-
Oklahoma Health Sciences Center, Oklahoma City.
tamination) and white blood cells (WBCs, repre-
Reprint requests: D. J. Flournoy, PhD, VAMC (113), 921 N.E. 13th senting sputum). Since 1974, numerous investi-
St., Oklahoma City, OK 73104.
gators have established guidelines for evaluating
0 1993 by the Association for Practitioners in Infection Control, Inc. sputum adequacy. three of these
0196-6553/93 $0.100 + 0.10 1?/46/42363 studies was the macroscopic appearance of spu-
A
Volume 21, Number 2 Flournoy and Davidson

Takle II, Criteria for grading the quality of

sputum specimens
Squamous
Grade epithelial cells WBCS

GOGCP Q-10 usually > 20

Fair* 11-19 usually > 10
Poor >19 >lO
Inadequate 219 <lO

IO x objective, IO x ocular (low, dry power) was used; counts are per field.
*Specimens with < 10 squamous epithelial cells were judged to be good;
those with 11 to 19 squamous epithelial cells were judged fair, regardless of
number of WE0

turn samples mentionede4, 8,9 In an anecdotal

comment, Murray and Washington4 noted that the
presence of blood, mucus, or saliva (as detected
with the naked eye) was an unreliable predictor of Fig. 1. Sputum culture container with collection-guide
sputum quality. Although Martin and associates
label.
mentioned the presence of saliva, mucus, blood,
and pus, no further details were presented. Hei-
neman and Radano warned about the inaccuracy
of trying to judge sputum quality by appearance.
Nevertheless, since 1974 no empiric studies
related specimen quality to macroscopic ap-
pearance.

METHODS
The study period was from October 199 1 to
December 1991. The Gram stain12 was used to
grade specimen quality. Specimens were graded
according to the presence of oropharyngeal ma-
terials such as squamous epithelial cells (SECs)
and polymorphonuclear leukocytes (representing
sputum, Table 1). This grading system was based
on previous studies. i, 4,6, l1 Most specimens consist
of varying amounts of sputum and saliva. Grading
is a method of estimating the proportion of these
components in the specimen. Good and fair Fig. 2. Watery ES specimen with heavy froth (side view).
specimens have minimal and moderate oropha-
ryngeal contamination (e.g., SECs), respectively.
The amount of polymorphonuclear leukocytes experience at the bench, read e Gram stains For
(WBCs) indicates how much sputum is present quality control, a Gram-stained control slide with
Cs means a large amount of sputum). known bacteria was evaluated weekly to ensure
Poor specimens have a disproportionately large proper staining characteristics.
concentration of oropharyngeal material relative To eliminate interrater variation, one microbi-
to sputum. Inadequate specimens have a large ologist who was blinded to specimen quality
amount of oropharyngeal materials and little if results, observed, described, and then noted the
any sputum. In our laboratory, inadequate speci- appearance of all sputum samples. Specimens
mens (representing 2% of all sputum specimens were described according to their consistency
for 199 1) were routinely discarded after notifica- (watery, mucoid, mucopurulent), appearance
tion of the charge nurse, whereas good, fair, and (flecks, blood, color) and amount of froth or
poor specimens were all cultured. Five medical bubbles (Figs. 1 through 6). Mucoid specimens
technologists, each with more than 5 years of appeared as transparent or translucent with or
 Floumoy and Davidson April 1993

Mucoid ES specimen with white flecks and mod- Fig. 5. Mucopurulent yellow ES specimen with no froth
erate froth (bottom view). (bottom view).

Mucoid-mucopurulent yellow ES specimen with Fig. 6. Mucopurulent yellow TRA specimen with no iroth,
slight to moderate froth (bottom view). (side view).

without debris; mucopurulent specimens were obtain percutaneous needle in

opaque and usually yellow. A mucoid- cause are more likely to yield
mucopurulent was predominantly mucoid. mens than are ES samples,* I4 da
Froth13 and flecks of tissue and debrislo have been different specimens were examined separately.
noted as descriptive terms for sputum samples. Statistical evaluation was performed by 2 x 2 x2
The amount of froth was semiquantitated in test (one-tailed, one degree of freedom, level of
gradations from a reading of heavy (bubbles significance p < 0.01).
covering the entire specimen surface) to none.
Specimens included expectorated sputum (ES) RESULTS
or tracheal aspirates (TRA). For the purpose of this Three hundred thirty-three s m samples for
study, T s were defined as endotracheal or culture were Gram stained evaluated for
suctioned tracheal secretions obtained through an quality in a 398-bed veterans ~~s~i~a~ in the
endotracheal tube or tracheostomy; this classifi- midwest. Specimens were obtained from 12 hos-
cation does not include transtracheal aspirates pital units, including three units from critical care
Volume 21, Number 2 ~loumoy and Davidson

Comparison of specimen quality by method of collection

ES TRA TOTAL

rade No. % No. % No. o/e

Good 100 44 75 72 175 53

Fair 49 21 14 13 63 19
Poor 79 35 16 15 95 29
TOTAL 228 100 105 100 333 100

3. Comparison of specimen consistency and grade

Number of Specimens

ES TRA

onaistency* Good Fair Poor TOTAL Good Fair Poor TOTAL

Watery 2 5 9 16 3 0 1 4
Watery-mucoid 6 6 15 27 13 1 5 19
Watery-mucopurulent 3 2 0 5 13 3 3 19
Mucoid 49 29 38 116 9 4 2 15
Mucoid-mucopurulent 16 4 13 33 14 2 2 18
Mucopuruient 24 3 4 31 23 4 3 30
TOTAL 100 49 79 228 75 14 16 105
_
Figures are in number of specimens. Mucopurulent ES specimens were more likely to be good or fair than were nonmucopurulent ES specimens (p < 0.01).
Mucoid-mucopuruleni specimens were predominantly mucoid; watery-mucopurulent specimens were predominantly watery.

(surgical intensive care, medical intensive care, DISCUSSION

and coronary care), six from medicine, and one Poor sputum specimens could potentially
each from surgery, clinics, and the emergency an important effect on the welfare of patients with
department. More than 95% of the TRAs were pneumonia in the United States. Our ho al has
collected in the critical care units. Nineteen 398 beds, admitted 8193 patients, and 2161
percent of the 333 specimens were collected in the routine sputum cultures in 199 1. According to the
critical care units. During the study period, fewer American Hospital Association, there are 6 14 1
than 1% of all specimens submitted for culture U.S. hospitals, with 1,047,851 beds and
were inadequate and were therefore not analyzed. 33,301,614 admissions for 1990. If other hospi-
Table 2 describes the specimens by grade and tals had culture rates similar to ours (on the basis
collection method. Although TRAs were generally of number of hospital beds or admissions), be-
of higher grade, they represented only 32% of the tween 5 and 8 million sputum cultures would have
total specimens. Poor specimens represented 15% been performed in 1990. If 35% (Table 2) of the
of the TRAs and 35% of the ES specimens sputum samples from these cultures were poor
(p < 0.001). Table 3 compares the quality of ES specimens, 1.75 to 2.8 million poor specimens
and T specimens with their specimen consis- would have been sent for culture in 1990. Improv-
tency. Most ES specimens were mucoid in appear- ing the adequacy of sputum specimens could
ance and varied in grade. therefore have a large impact on personnel time,
Of the other characteristics studied, only yellow expenditures, and timely diagnosis and treatment
color in the specimen was statistically significant. of patients with pneumonia.
In 233 ES specimens, the presence of a yellow Efficient and timely diagnosis and treatment of
color was more likely to be found in good or fair bacterial pneumonia require that physicians order
specimens than in poor specimens (p < 0.01). In sputum cultures and antimicrobial susceptibility
addition, yellow ES and TRA specimens were tests on infected patients, nurses obtain adequate
more likely to be mucopurulent than mucoid sputum specimens, and microbiology personnel
(p < 0.001). There were no significant associa- inoculate the specimen onto appropriate media
tions between sputum grade and amount of froth, and then correctly incubate, interpret, and report
presence of flecks, or presence of blood in spec- the culture results. The purpose of ordering a
imens. sputum culture is to determine the etiologic agent
 Floumoy and Davidson ADril 1993

or agents (by ruling in or ruling out an organism). patient first wakes up. Loud tracheal rhonchi
Culture is most helpful when ordered for patients should precede the expectoration of sputum.
who are likely to have pneumonia. Patients with When a cough is dry (tracheal rhonchi inaudible),
bacterial pneumonia commonly have changing the specimen is supralaryngeal in origin and
pulmonary infiltrates, shown by chest radiography should not be cultured.17 Indeed, the potential
plus several of the following signs or symptoms: value of ES in the diagnosis of lower respiratory
fever ( > 38 C), productive cough, dyspnea, and tract disease may be directly related to the volume
altered breath sounds compatible with pneumonia of the specimen (the more specimen there is, the
(rales, egophony, pectoriloquy, etc.).2z I6 However, better the diagnostic potential), because small-
cultures are not always ordered for infected volume samples (< 5 ml) are more likely to be
patients and speci.mens often (35% in this study) contaminated with oropharyngeal materials than
are poor. Laboratory personnel therefore also are large-volume samples. l8 This seems plausible;
evaluate the specimen quality to determine a patient with a productive cough is more likely to
whether the culture should be set up and how have rinsed or diluted the oropharyngeal cavity
much emphasis (speciation and antimicrobial with sputum through frequent expectoration and
susceptibility testing) to place on culture isolates. is therefore less likely to have a poor specimen.
In one community hospital survey, sputum collec- Unfortunately, supervising the collection of ES
tion supervision or instruction by nurses occurred samples is often a low-priority activity for a busy
in only 33% of the cases, 50% of the specimens nurse. In addition, several factors can make it
were of poor or uncertain quality, and in-service difficult to obtain good specimens from a patient,
training of nursing personnel on proper collection including a patient who is uncooperative, unable
techniques failed to effect long-term changes in to cooperate, or has an unproductive cough. In
collecting practices. However, specimen screen- some lower respiratory tract infections (legionnel-
ing improved the quality of specimens cultured losis, pneumocystic and mycoplasmic infections,
through rejection of unsatisfactory samples.14 In Q fever, and psittacosis), patients do not produce
this same study, 20% of patients with cultures had sputum. A dehydrated patient may have a non-
no evidence of lower respiratory tract infection. productive cough.
Indeed, Lentino and Lucks found that 52% of What can the nurse do when he or she is unable
sputa submitted for culture were from patients to collect an adequate specimen? Other options for
with no evidence of pneumonia. obtaining diagnostic specimens include induction
The appearance of an ES sample is not associ- of sputum, percutaneous transtrachael aspiration,
ated with specimen quality in most cases; most ES bronchoscopy, and lung biopsy.
samples are nonmucopurulent. It is therefore these alternate methods of sp
difficult to predict which specimens are good on require physicians orders, more invasive proce-
the basis of appearance. An alternative means of dures, or involvement of other health care profes-
decreasing the number of poor specimens is to sionals (respiratory therapists), resulting in addi-
increase the number of specimens for which tional time. The collection of lower resp
collection is supervised. In our hospital, periodic tract specimens by alternate methods
spot surveys have indicated that most specimens therefore be minimized.
are not collected under supervision. Specimen Few studies have examined the relationship
supervision should include patient education and between macroscopic cues and specimen quality.
nursing observation during collection. Education Our findings are in agreement with those of
may include oral hygiene instructions before Murray and Washington4 who reported that the
specimen collection, followed by a description of presence of blood, mucus, and saliva were unre-
expectoration technique. Because the collection of liable in assessing ES quality, and of Heineman
many of our ES specimens is not supervised,14 the and Radano,9 who warned about the i
following written instructions are placed on our judging specimen quality visually.
sputum containers: Collect in early morning. findings show that ES quality vari
Remove dentures Brush teeth, mouth, tongue. quality and consistency (Table 3). Although the
Rinse mouth well three times with tap water. quality of most ES samples cannot be predicted
Cough (deeply to raise from lungs) sputum into from their appearance, some are predictable; this
sterile cup. Place lid on tightly. Do not collect spit. fact has not been emphasized in the literature. A
Results from spit are misleading. mucopurulent-yellow specimen is easily identified
Also, nurses should be aware that the best time (Figs. I through 6). Good or fair ality was found
to collect sputum is in the early morning, when the in 87% of mucopurulent ES samples and 79% of
AJIC
Volume 21, Number 2 Flourmy and DavicLson

yellow ES samples. The yellow color usually analysis of expectorated sputum. Mayo Clin Proc 1975;50:
339-44.
Cs (e.g., neutrophils, eosinophils). A
5. Van Scoy RE. Bacterial sputum cultures-a clinicians
mucoid specimen with yellow flecks or a mucopu- viewpoint. Mayo Clin Proc 1977;52:39-41.
ruler& yellow ES speci.men can indicate either the 6. Geckler RW, Gremillion DH, McAllister CM, Ellenbogen C.
presence of infection (neutrophils) or asthma Microscopic and bacteriologic comparison of paired sputa
(eosinophils). *O Interestingly, sputum can be and transtrachael aspirates. J Clin Microbiol 1977;6:
396-9.
green as a result of degeneration of leukocytes
7. Heineman HS, Chawla JK, Lofton WM. Misinformation
after standing a long time or the presence of from sputum cultures without microscopic examination.
Psetldomonas aemginosa, a green-pigmented or- J Clin Microbial 1977;6:518-27.
ganism.* 8. Martin RS, Sumarah RK, Robart EM. Assessment of
In addition, it is also important to recognize that expectorated sputum for bacteriologic analysis based on
polymorphs and squamous epithelial cells: six month
not all TRAs are good specimens. Fifteen percent
study. J Clin Microbial 1978;8:635-7.
of our T specimens were graded poor. Indeed, 9. Heineman HS, Radano RR. Acceptability and cost savings
oropharyngeal contamination of transtracheal as- of selective sputum microbiology in a community teaching
pirates has been reported to occur in 2% to 19% of hospital. J Clin Microbial 1979;10:567-73.
cases. i* 6*22,*j This problem occurs when patients 10. Wong LK, Barry AL, Horgan SM. Comparison of six
different criteria for judging the acceptability of sputum
aspirate oropharyngeal materials or the lower
specimens. J Clin Microbial 1982;16:627-31.
respiratory tract has chronic colonization. Also, 11. Sodeman TM, Colmer J. Microbiology of the respiratory
tracheal catheters can be misdirected during tract. Lab Med 1983;14:96-101.
insertion and subsequent culture results can 12. Snyder B. Pitfalls in the gram stain, with a proposed rapid
therefore provide misleading information. Nurses technic. Lab Med 1970;1:41-4.
13. Dorn GL, Land GA, Smith KE. The compromised host:
should therefore carefully obtain TRAs with sterile
quantitative sputum analysis with a nontoxic mucolytic
technique. Although a tvunstracheal aspirate is agent. Lab Med 1980; 11: 183-9.
more accurate than is an ES or TRA specimen as 14. Jacobson JT, Burke JP, Jacobson JA. Ordering patterns,
a diagnostic tool, the collection procedure is more collection, transport, and screening of sputum cultures in
invasive.24 a community hospital: evaluation of methods to improve
results. Infect Control 1981;2:307-1 I.
In conclusion, other than in the case of mucopu-
15. American Hospital Association. AHA hospital statistics: a
rulent specimens, we found little association comprehensive summary of U.S. Hospitals. 1991-92 ed.
between physical characteristics of ES samples Chicago: American Hospital Association, 199 1.
and specimen quality. Although current nursing 16. Lentino JR, Lucks DA. Nonvalue of sputum culture in the
and microbiology textbooks recommend super- management of lower respiratory tract infections. J Clin
Microbial 1987;25:758-62.
vised collection of sputum, no empiric studies
17. Saadah HA, Nasr FL, Shagoury ME. Washed sputum
document the value of supervision. For now, we Gram stain and culture in pneumonia. J Okla State Med
recommend that the collection of all expectorated Assoc 1980;73:354-9.
sputum specimens be supervised for patients who 18. Allen JC, Beam TR. Lower respiratory infections. In: Allen
can cooperate. In the meantime, we are collecting JC, Beam TR. Infectious disease for the house officer.
Baltimore: Williams and Wilkins, 1982~51-8.
data to determine the usefulness of supervised
19. Ramsdell JW, Stool EW. Mycoplasmal pneumonia, orni-
specimen collection as a means of improving thosis, Q fever and Legionnaires disease. In: Bordow
specimen quality. Stool EW, Moser EM, eds. Manual of clinical problems in
pulmonary medicine. Boston: Little, Brown, 1981;122-8.
We thank Dorothy C. Belknap, Bernice Yates (Nursing Ser-
20. Epstein RL. Constituents of sputum: a simple method. Ann
vice), Steve Darter (Laboratory Service), and all Microbiology Intern Med 1972;77:259-65.
Personnel (Laboratory Service) for their help in preparing the
21. Emerson P. Sputum. In: FD Hart, ed. Frenchs index of
article.
differential diagnosis, 12th ed. London: Wright, 1989;
796-8.
References 22. Irwin RS, Demers RR, Pratter MR, Erickson AD, Farrugia
1. Porschen R. Experience with microscopic screening pro- R, Taplitz C. Evaluation of methylene blue and squamous
gram for sputum specimens. Health Lab Sci 1977; 14: 17- epithelial cells as oropharyngeal markers: a means of
-.
61. identifying oropharyngeal contamination during transtra-
2. Floumoy DJ, Darter SK, Murray CK, Catlett R. The cheal aspiration. J Infect Dis 1980; 14 1: 165-7 1.
influence of patient location and physician on sputum 23. Schoutens E, DeKoster JP, Vereerstraeten J, Tombroff M,
adequacy in a Veterans Administration medical center. Yourasso E. Use of transtrachael aspiration in the bacte-
Lab Med 1990;21:653-7. riologic diagnosis of bronchopulmonary infections. Bio-
3. Bartlett RC. Medical microbiology-quality, cost, and medicine 1973; 19: 160-3.
clinical relevance. New York: John Wiley and Sons, 1974. 24. Irwin RS, Corrao WM. A perspective on sputum analyses
4. Murray PR, Washington JA. Microscopic and bacteriologic in pneumonia. Respir Care 1979;24:503-9.