Induced Sputum Guidelines for Practice 2015

Version: This replaces the Induced Sputum Guidelines for Practice, May 2012
Review Date: October 2018
Contact: Greg Stretton, Senior Physiotherapist Specialty Medicine Cancer Services
and Eleanor Douglas, Lecturer/Practitioner Physiotherapist Ext: 55292 / 56142

Disclaimer
This guideline has been registered with the Nottingham University Hospitals Trust.
However, clinical guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual clinician. If in any
doubt regarding this procedure, contact a senior colleague. Caution is advised when
using guidelines after the review date. Please contact the named above with any
comments / feedback. Please note this guideline is for sputum induction in adults
only.

Indications for Use

This protocol describes the procedure for gaining induced sputum samples from non-
expectorating patients, to assist in the diagnosis of pneumocystic carini pneumonia
(PCP), fungal and viral infections. Sputum induction has been demonstrated to be a
sensitive and cost-effective technique in the diagnosis of PCP, it is a method that
saves time and is less invasive than a bronchoscopy and Bronchi Alveolar Lavage
(BAL) (Cruciani et al 2002). An induced sputum can also be a useful tool in
diagnosing pulmonary TB (Scheicher et al, 2003; McWilliams et al, 2002).

Precautions
Asthma – the induced sputum procedure can cause bronchospasm so known
asthmatics should be monitored throughout for signs of intolerance.

Patients with a reduced FEV1 – see above.

High percentage oxygen support (>40%) – the induced sputum procedure requires
the ultrasonic nebulizer which does not have a high flow-rate. Therefore it cannot be
used in conjunction with oxygen via a T-piece. If a patient requires oxygen they
must be on either nasal cannula or nasal optiflow.

Tuberculosis – any patient suspected of having TB should have induced sputum

carried out in a negative pressure room, where the air content can be ventilated out.

These factors need to be weighed up against the clinical need for a sputum sample.

Contraindications
Pulmonary Embolism
Cardiovascular instability
Pneumothorax
Fractured ribs / chest trauma
Bronchospasm
Patient is independently expectorating
Patient has eaten within 4 hours

Ultrasonic Nebuliser Guideline 2015

Complications
Nausea/Vomiting – limited if the patient has been made nil by mouth for 4-6 hours.

Bronchospasm – If the patient shows any sign of bronchodpasm (reduced SpO2;

increased work of breathing; audible wheeze on auscultation)

Oxygen Desaturation – SpO2 monitoring throughout is recommended.

Equipment List

1. One metal trolley

2. NaCl (7%) 7 x 4ml hypertonic saline - 28mls prescribed
3. 2 x Salbutamol 2.5mg prescribed (1 pre-investigation, 1 PRN).
4. Ultrasonic Nebuliser
5. Normal nebuliser compressor and attachments
6. Disposable cup and lid for ultrasonic nebuliser
7. Large bottle of sterile water
8. Elephant tubing
9. Oxygen filter
10. Scissors
11. Face mask with holes covered
12. Nasal cannula if the patient requires additional oxygen throughout the
procedure
13. Oxygen supply
14. Six sputum pots labeled and numbered
15. Sick bowl
16. FFP3 face-mask for the member of staff performing the procedure

Please note the use of 7% NaCl can be negotiated with the requesting consultant.
There is no acknowledged ideal concentration of NaCl for an induced sputum, varying
from 3-10% (Bell et al, 2004). NUH uses 7% as a standard because it is readily
available from pharmacy and has caused less cancellations. Previously NUH has
used lower NaCl solutions, requested from pharmacy, but this often led to the
procedure being cancelled due to the unavailability of the Nacl solution.

Procedure - Preparation

Action Rationale

Ensure a referral has been made
by a doctor (SHO or above) and
has been documented in the
medical notes.
The procedure has been
explained to the patient and
consent has been given.
Induced sputum requests must be through a
medical referral.
Minimizes distress and informs the patient of the
procedure. Confirms the patient is willing to
undertake the procedure.

The patient must be nil-by- To prevent the patient from vomiting and
mouth for 4 hours prior to the contaminating the sputum samples. It is

Ultrasonic Nebuliser Guideline 2015

procedure.
Check that 28mls of 7%
hypertonic saline has been
prescribed and collected from
pharmacy.
The procedure should be
performed in a negative
pressure room if at all possible,
especially if TB is suspected.
Procedure – Pre-Nebulisation
Obtain consent from the patient
on the morning of the
investigation.
Sit the patient upright in a chair
or on their bed.
The patient should be given
2.5mg Salbutamol prior to the
induced sputum if cardiovascular
status allows. NB. If the patient
is under a Haematologist, please
check with the haematology
doctor that they are in agreement
with this.
Ensure a PRN Salbutamol 2.5mg
nebuliser has been prescribed and
it setup so that it can be used
quickly in an emergency.
Gloves, apron and a, FFP3 facial-
mask should be worn by the
physiotherapist during the
procedure.
Auscultate the patient’s chest.
Set up the ultrasonic nebuliser
using sterile water in the
chamber, the amount of which is
indicated on the side of the
chamber.
Place a disposable cup in the top
of the ultrasonic nebuliser and fill
with 28mls of hypertonic saline.
The saline should be double
checked with 2 qualified members
of staff to confirm expiry date,
correct dosage and concentration
prior to administration
Place the filter on the ultrasonic
between the base and the shorter
Ultrasonic Nebuliser Guideline 2015
recommended that the procedure is font first
thing in the morning and the patient is NBM from
midnight.
Hypertonic saline is routinely available in 4ml vials
at 7%. If another dosage has been requested by
the medical team, it may take longer to arrive
from pharmacy.
If there is any uncertainty about the expected
infecting agent full protection must be taken. For
further details contact Infection Control on
extension 69502.
Confirms the patient is still willing to undertake
the procedure.
Provides a good position for the patient when
they are coughing.
This significantly reduces the likelihood of
bronchospasm (Pizzichini et al, 2002).
Haematology doctors may not be happy with the
cardiovascular risk out-weighing the
bronchospasm benefit of pre-nebulisation.
Salbutamol must be available incase the
procedure induces bronchospasm (Leigh et al
1994 and Castagaro et al 1999).
This reduces the amount of nebulised saline
inhaled by the therapist and protects them from
any harmful airborne particles expectorated by
the patient.
To ensure no bronchospasm is present.
To avoid contamination.
To avoid contamination and ensure saline
administered is of correct dosage and
concentration and that it has not expired
This reduces the likelihood of external infectious
agents being passed into the patient.
piece of tubing.
Place the lid on the cup and use 2 This will allow the nebulised saline to be picked
sections of elephant tubing to up by the through-flow of the nebuliser.
connect the cup to the nebuliser
(this will fit on top of the filter).
A second length of elephant This carries the nebulised saline to the patient.
tubing (approximately 12 sections
long) attaches to the other outlet
on the cup lid and to the face
mask.

Use a mouth-piece or a face mask To provide maximum nebulisation of the

with the side holes taped up. The hypertonic saline. Spectacles / dressing reduces
patient may wish to wear the amount of saline that is blow into the eye
spectacles or a dressing over the region and improves patient comfort and
top of the mask. compliance.

Procedure – During Nebulisation

Monitor the patient’s oxygen Desaturation during the procedure may occur
saturations during the procedure (Leigh et al 1994; Castagnaro et al 1999)
and provide supplementary
oxygen via nasal cannula if
saturations drop below patient’s
normal range.
After the 1st minute, auscultate Bronchospasm can occur at any time and can
the patient to assess whether present very quickly. All patients should be
there is any bronchospasm monitored throughout the procedure. If any
present. This should also be signs of bronchospasm present, stop the
done, regardless of time, if the investigation and immediately commence the
patients sounds wheezy or reports second Salbutamol neb.
tightness.
If the patient appears in If bronchospasm occurs, the patient may require
respiratory distress, ie. Increased higher amounts of Oxygen to remain within their
work of breathing, bronchospasm normal SpO2 range.
and reduced SpO2, stop the
hypetonic saline and give the PRN
Salbutamol via 6-10l of O2, to
bring the SpO2 back into a normal
range.
Allow the patient to inhale the To illicit a spontaneous cough.
nebuliser for 20-30 minutes, or
until it has all been inhaled,
temporarily stopping it when the
patient expectorates (Scheicher et
al, 2003).
If a cough is not elicited gentle To try to mobilise secretions in order to gain the
vibrations or percussion over the sputum specimens.
patients chest can be carried out
in sitting or side lying unless
patient has any contraindicating
factors e.g. rib Fractures

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The first specimen (1) is This sputum is from more proximal airways.
discarded.
The next 4 samples are collected These can then be labeled and sent for M,C & S
in sterile sputum jars. These jars (2), virology (3), fungal (4) and PCP (5).
should be numbered 2-5.
If less than 4 samples are The M C & S is used to identify “more common”
obtained, disregard M,C & S. infections. For patients that are appropriate for
an induced sputum it is more likely that Viral,
Fungal and PCP infections are what is being
investigated.
If 6 samples are obtained, This will be the deepest most distal airway
disregard 1 and 2 and send the sample.
latter 4. Always send the last
sample expectorated for PCP.
There may be other tests that the This test may be requested by the medical team
medical team require such as to identify / rule out a particular infection.
Acid-fast Bacilli (AFB, for TB),
Actinomycosis & Nocardia.
The test is stopped if: This is to ensure the patient is willing to
o The patient has continue, it is clinically indicated and it is safe to
expectorated 6 times. do so.
o The patient vomits.
o The patient goes into
bronchospasm.
o SpO2 drops below
acceptable limits.
o The patient does not wish
to continue.

Procedure – Post Nebulisation

Send the samples immediately to To allow analysis to be made as soon as

microbiology. possible.
Document the outcome of the To ensure communication with the medical team
procedure in the medical notes. and to cover yourself from a legal position.
When the procedure is finished To ensure the disposable equipment is disposed
disregard the elephant tubing, of appropriately as clinical waste.
disposable cup. Lid and
mask/mouthpiece in a yellow
clinical waste bin.
Clean the chamber and surfaces To avoid cross infection
of the ultrasonic nebuliser with
hard surface wipes, as outlined in
the cleaning protocol
A second induced sputum is (Paggiaro et al, 2002).
contraindicated for 48 hours.

References

Ultrasonic Nebuliser Guideline 2015

Bell D, Leckie V, McKendrick M. Use of the induced sputum procedure in the
investigation of smear-negative pulmonary turberculosis. Oxford Journals: Clinical
Infectious Diseases 38 (10) p1504-1505
Castagno A, Chetta A, Foresi A, D’Ippolito R, Malorgio R et al. Effect of sputum
induction on spirometric measurements and arterial oxygen saturation in asthmatic
patients, smokers and healthy subjects. Chest 1999. 116(4); 941-945

Cruciani M, Marcati P, Malena M, Bosco O, Serpelloni G and Mengoli C. Meta analysis

of diagnostic procedures for pneumocystis carinii pneumonia in HIV infected patients.
European Respiratory Journal 2002. 20; 982-989

Leigh TR, Kirby K, Gazzard BG and Collins JV. Effects of sputum induction on arterial
oxygen saturation and spirometry in HIV infected patients. European Respiratory
Journal 1994. 7(3): 453 458

McWilliams T, Wells AU, Harrison AC, Lindstrom S, Cameron RJ, Foskin E. Induced Sputum
and bronchoscopy in the diagnosis of pulmonary tuberculosis. Thorax 2002; 57(12): 1010-1014

Olivieri D, D’Ipolito R and Chetta A. Induced sputum: diagnostic value in interstitial

lung disease. Current Opinion in Pulmonary Medicine 2000. 6(5); 411-414

Paggiaro PL, Chanez P, Holz O, Ind PW, Djukanovic R, Maestrelli P and Sterk PJ.
Sputum induction. European Respiratory Journal 2002 20: Supple. 37: 3 – 8.

Pizzichini E, Leigh R, Djukanovic R and Sterk PJ. Safety of induced sputum. European
Respiratory Journal 2002 20: Supple. 37: 9 – 18.

Pryor JA and Prasad AS. Physiotherapy for Respiratory and Cardiac Problems.2002.
Third Edition. Churchill Livingstone. Chapter 6

Marcos Eduardo Scheicher ME, Filho JT, Vianna EO Sputum induction: review of
literature and proposal for a protocol. Sao Paulo Med Journal 2003; 121(5):213-219

Ultrasonic Nebuliser Guideline 2015