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
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

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 Bartlett’s 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-

. Hei- neman and Radano’ warned about the inaccuracy of trying to judge sputum quality by appearance. one microbi- to sputum. SECs). regardless of number of WE0 turn samples mentionede4. Grading is a method of estimating the proportion of these components in the specimen. since 1974 no empiric studies related specimen quality to macroscopic ap- pearance. Sputum culture container with collection-guide sputum quality. those with 11 to 19 squamous epithelial cells were judged fair. (watery. dry power) was used. or saliva (as detected with the naked eye) was an unreliable predictor of Fig. described. mucus. IO x ocular (low. inadequate speci. Table 1). Mucoid specimens technologists. Nevertheless. 1 through 6). read e Gram stains For (WBCs) indicates how much sputum is present quality control. Number 2 Flournoy and Davidson Takle II. counts are per field. fair. Specimens mens (representing 2% of all sputum specimens were described according to their consistency for 199 1) were routinely discarded after notifica. i. 1.A Volume 21. color) and amount of froth or poor specimens were all cultured. blood. whereas good. METHODS The study period was from October 199 1 to December 1991. Watery ES specimen with heavy froth (side view). Although Martin and associates’ label. *Specimens with < 10 squamous epithelial cells were judged to be good. and then noted the any sputum. appearance tion of the charge nurse. known bacteria was evaluated weekly to ensure Poor specimens have a disproportionately large proper staining characteristics. Specimens were graded according to the presence of oropharyngeal ma- terials such as squamous epithelial cells (SECs) and polymorphonuclear leukocytes (representing sputum. l1 Most specimens consist of varying amounts of sputum and saliva. Inadequate specimens have a large ologist who was blinded to specimen quality amount of oropharyngeal materials and little if results. respectively. Good and fair Fig. a Gram-stained control slide with Cs means a large amount of sputum). mucopurulent). blood. specimens have minimal and moderate oropha- ryngeal contamination (e. concentration of oropharyngeal material relative To eliminate interrater variation. appearance of all sputum samples. each with more than 5 years of appeared as transparent or translucent with or . This grading system was based on previous studies. and (flecks. mucoid. In our laboratory. Five medical bubbles (Figs.9 In an anecdotal comment. 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. observed. 4. 8.g. Murray and Washington4 noted that the presence of blood. The amount of polymorphonuclear leukocytes experience at the bench. mentioned the presence of saliva. 2.6. The Gram stain12 was used to grade specimen quality. mucus. and pus. no further details were presented.

Mucopurulent yellow ES specimen with no froth erate froth (bottom view). including three units from critical care .‘* I4 da Froth13 and flecks of tissue and debrislo have been different specimens were examined separately. this classifi. Statistical evaluation was performed by 2 x 2 x2 The amount of froth was semiquantitated in test (one-tailed. slight to moderate froth (bottom view). Fig. A mucoid. (bottom view). Specimens included expectorated sputum (ES) RESULTS or tracheal aspirates (TRA). mens than are ES samples. Mucopurulent yellow TRA specimen with no iroth. midwest. (side view). covering the entire specimen surface) to none. noted as descriptive terms for sputum samples. without debris. For the purpose of this Three hundred thirty-three s m samples for study. mucopurulent specimens were obtain percutaneous needle in opaque and usually yellow. one degree of freedom. 6. Floumoy and Davidson April 1993 Mucoid ES specimen with white flecks and mod. 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. Mucoid-mucopurulent yellow ES specimen with Fig. 5. cause are more likely to yield mucopurulent was predominantly mucoid. level of gradations from a reading of heavy (bubbles significance p < 0.01). Specimens were obtained from 12 hos- cation does not include transtracheal aspirates pital units.

” If other hospi- Table 2 describes the specimens by grade and tals had culture rates similar to ours (on the basis collection method.Volume 21. DISCUSSION and coronary care). medical intensive care. inoculate the specimen onto appropriate media tions between sputum grade and amount of froth. % No. admitted 8193 patients. yellow ES and TRA specimens were tests on infected patients.001). Our ho al has collected in the critical care units.851 beds and were inadequate and were therefore not analyzed. fewer American Hospital Association. Poor specimens represented 15% been performed in 1990. hospitals.8 million poor specimens and T specimens with their specimen consis. and report presence of flecks. and timely diagnosis and treatment color in the specimen was statistically significant. or presence of blood in spec. and then correctly incubate. Mucoid-mucopuruleni specimens were predominantly mucoid.01).047. Table 3 compares the quality of ES specimens. Although TRAs were generally of number of hospital beds or admissions). six from medicine. they represented only 32% of the tween 5 and 8 million sputum cultures would have total specimens. clinics. and the emergency an important effect on the welfare of patients with department. only yellow expenditures. 33. (surgical intensive care. There were no significant associa. Nineteen 398 beds.301. Of the other characteristics studied. In 233 ES specimens. The purpose of ordering a imens. would have been sent for culture in 1990. therefore have a large impact on personnel time. there are 6 14 1 than 1% of all specimens submitted for culture U. 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. 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. Number 2 ~loumoy and Davidson Comparison of specimen quality by method of collection ES TRA TOTAL rade No. In sputum cultures and antimicrobial susceptibility addition. and microbiology personnel (p < 0. ing the adequacy of sputum specimens could ance and varied in grade. and 2161 percent of the 333 specimens were collected in the routine sputum cultures in 199 1. nurses obtain adequate more likely to be mucopurulent than mucoid sputum specimens. 1. Most ES specimens were mucoid in appear.S. Mucopurulent ES specimens were more likely to be good or fair than were nonmucopurulent ES specimens (p < 0. Improv- tency. with 1. be- of higher grade. If 35% (Table 2) of the of the TRAs and 35% of the ES specimens sputum samples from these cultures were poor (p < 0. 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. and one Poor sputum specimens could potentially each from surgery. During the study period. the culture results.614 admissions for 1990.01). More than 95% of the TRAs were pneumonia in the United States. of patients with pneumonia.001). % No. According to the critical care units.75 to 2. watery-mucopurulent specimens were predominantly watery. interpret. sputum culture is to determine the etiologic agent .

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. and lung biopsy.14 In Q fever. Do not collect spit. better the diagnostic potential). 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. specimen screen. of sputum. Indeed. Although the Rinse mouth well three times with tap water. bacterial pneumonia commonly have changing the specimen is supralaryngeal in origin and pulmonary infiltrates. A Results from spit are misleading.17 Indeed. sputum containers: “Collect in early morning. are not collected under supervision.9 who warned about the i following written instructions are placed on our judging specimen quality visually. dyspnea. patients do not produce this same study. Floumoy and Davidson ADril 1993 or agents (by ruling in or ruling out an organism). because small- cultures are not always ordered for infected volume samples (< 5 ml) are more likely to be patients and speci. fact has not been emphasized in the literature. In addition. productive cough. productive cough. some lower respiratory tract infections (legionnel- ing improved the quality of specimens cultured losis. Good or fair ality was found to collect sputum is in the early morning.” A dehydrated patient may have a non- no evidence of lower respiratory tract infection. unable techniques failed to effect long-term changes in to cooperate.” mucopurulent-yellow specimen is easily identified Also. mouth. In our hospital. Education Our findings are in agreement with those of may include oral hygiene instructions before Murray and Washington4 who reported that the specimen collection.). several factors can make it were of poor or uncertain quality. 50% of the specimens nurse. and tract disease may be directly related to the volume altered breath sounds compatible with pneumonia of the specimen (the more specimen there is. resulting in addi- increase the number of specimens for which tional time. In collecting practices. and of Heineman many of our ES specimens is not supervised.14 the and Radano. Specimen Few studies have examined the relationship supervision should include patient education and between macroscopic cues and specimen quality. quality of most ES samples cannot be predicted Cough (deeply to raise from lungs) sputum into from their appearance. obtaining diagnostic specimens include induction The appearance of an ES sample is not associ. mucus. Because the collection of liable in assessing ES quality. or involvement of other health care profes- decreasing the number of poor specimens is to sionals (respiratory therapists). quality and consistency (Table 3). It is therefore these alternate methods of sp difficult to predict which specimens are good on require physician’s orders. pneumocystic and mycoplasmic infections. shown by chest radiography should not be cultured. I through 6). the potential plus several of the following signs or symptoms: value of ES in the diagnosis of lower respiratory fever ( > 38” C). who are likely to have pneumonia. followed by a description of presence of blood. training of nursing personnel on proper collection including a patient who is uncooperative. 20% of patients with cultures had sputum. is therefore less likely to have a poor specimen. Loud tracheal rhonchi Culture is most helpful when ordered for patients should precede the expectoration of sputum. nursing observation during collection. An alternative means of dures. The collection of lower resp collection is supervised. In one community hospital survey. and saliva were unre- expectoration technique. most ES bronchoscopy. nurses should be aware that the best time (Figs. egophony. However. findings show that ES quality vari Remove dentures Brush teeth. patient first wakes up. and psittacosis). this sterile cup. and in-service difficult to obtain good specimens from a patient. when the in 87% of mucopurulent ES samples and 79% of . sputum collec. periodic tract specimens by alternate methods spot surveys have indicated that most specimens therefore be minimized. l8 This seems plausible. the (rales. samples are nonmucopurulent. ated with specimen quality in most cases.mens often (35% in this study) contaminated with oropharyngeal materials than are poor. Place lid on tightly. some are predictable. Patients with When a cough is dry (tracheal rhonchi inaudible). Laboratory personnel therefore also are large-volume samples. 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. or has an unproductive cough. Unfortunately. pectoriloquy. tongue. etc. through rejection of unsatisfactory samples. more invasive proce- the basis of appearance. percutaneous transtrachael aspiration.2z I6 However.

2:307-1 I. 199 1. Colmer J. In: FD Hart. J Clin Microbial 1977. Mycoplasmal pneumonia. Farrugia 1. Although current nursing 16. Tombroff M. Yourasso E. A perspective on sputum analyses 4. Manual of clinical problems in pulmonary medicine. Taplitz C. a diagnostic tool. eosinophils). In the meantime. Bernice Yates (Nursing Ser- 20. Hospitals. Wong LK. Sputum. Irwin RS. Stool EW. Ramsdell JW. Assessment of In addition. Mayo Clin Proc 1977. viewpoint. insertion and subsequent culture results can 12.AJIC Volume 21. presence of infection (neutrophils) or asthma Microscopic and bacteriologic comparison of paired sputa (eosinophils). Snyder B.16:627-31. Mayo Clin Proc 1975. Allen JC. Martin RS. J Okla State Med recommend that the collection of all expectorated Assoc 1980. Robart EM. sputum can be and transtrachael aspirates. Medical microbiology-quality. Microbiology of the respiratory tracheal catheters can be misdirected during tract. Ann vice). Washed sputum document the value of supervision. and screening of sputum cultures in invasive.52:39-41. The compromised host: should therefore carefully obtain TRAs with sterile quantitative sputum analysis with a nontoxic mucolytic technique. Use of transtrachael aspiration in the bacte- Lab Med 1990. Horgan SM. The yellow color usually analysis of expectorated sputum. 1989.6: 396-9. Geckler RW. 24. Constituents of sputum: a simple method. no empiric studies 17. 19: 160-3. Bartlett RC. Brown. Belknap. Lab Med 1970. Gremillion DH. we are collecting JC. Number 2 Flourmy and DavicLson yellow ES samples. Experience with microscopic screening pro. Beam TR. vised collection of sputum. and all Microbiology Intern Med 1972. Respir Care 1979. Saadah HA. R. cases.21:653-7. Nurses technic. i* 6*22. Microscopic and bacteriologic in pneumonia. Bacterial sputum cultures-a clinician’s mucoid specimen with yellow flecks or a mucopu. Fifteen percent study. Darter SK. Sumarah RK. We thank Dorothy C. Floumoy DJ. Misinformation after standing a long time or the presence of from sputum cultures without microscopic examination. Cs (e. Van Scoy RE. the collection procedure is more collection. In: Allen can cooperate. Sodeman TM. The cheal aspiration. Land GA. J Infect Dis 1980. with a proposed rapid therefore provide misleading information.S. Murray CK. Ellenbogen C. of our T specimens were graded poor. Radano RR. Although a tvunstracheal aspirate is agent.. Demers RR. management of lower respiratory tract infections. clinical relevance. Bio- 3. Porschen R. riologic diagnosis of bronchopulmonary infections. For now. more accurate than is an ES or TRA specimen as 14.1:41-4. Evaluation of methylene blue and squamous gram for sputum specimens.77:259-65.24 a community hospital: evaluation of methods to improve results. sputum specimens be supervised for patients who 18. and medicine 1973. Nonvalue of sputum culture in the and microbiology textbooks recommend super. London: Wright. eds. Lucks DA. transport. neutrophils. Heineman HS. Vereerstraeten J. 13. J Clin Microbial 1982. between physical characteristics of ES samples Chicago: American Hospital Association. ruler& yellow ES speci. 1991-92 ed. Lab Med 1980. Also. J Clin Microbiol 1977. a green-pigmented or. we Gram stain and culture in pneumonia. Jacobson JA. 11.73:354-9. green as a result of degeneration of leukocytes 7. adequacy in a Veterans Administration medical center. Catlett R. epithelial cells as oropharyngeal markers: a means of -. Lab Med 1983. Erickson AD. J Clin Microbial 1987. cost. Chawla JK. Epstein RL. of selective sputum microbiology in a community teaching pirates has been reported to occur in 2% to 19% of hospital.50: 339-44. Jacobson JT. Pratter MR. respiratory tract has chronic colonization. 1982~51-8. Emerson P. McAllister CM. 11: 183-9. 796-8. Psetldomonas aemginosa.24:503-9.6:518-27. Burke JP. Steve Darter (Laboratory Service). Q fever and Legionnaires’ disease.*j This problem occurs when patients 10. 9. Indeed. data to determine the usefulness of supervised 19. influence of patient location and physician on sputum 23. Washington JA.10:567-73. 14: 17. Acceptability and cost savings oropharyngeal contamination of transtracheal as. . Lower respiratory infections. Corrao WM.g. 1974. Irwin RS. Pitfalls in the gram stain. differential diagnosis. 12th ed. References 22. Personnel (Laboratory Service) for their help in preparing the 21. Ordering patterns. 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. American Hospital Association.men can indicate either the 6. and specimen quality. we found little association comprehensive summary of U. In conclusion. Shagoury ME. Boston: Little. J Clin Microbial 1979. French’s index of article.8:635-7. Smith KE. Infect Control 1981.25:758-62. Murray PR. 61. Baltimore: Williams and Wilkins. Lofton WM. Moser EM. Comparison of six different criteria for judging the acceptability of sputum aspirate oropharyngeal materials or the lower specimens. 1981. *O Interestingly.122-8.14:96-101.*’ 8. In: Bordow specimen quality. Lentino JR. identifying oropharyngeal contamination during transtra- 2. AHA hospital statistics: a rulent specimens. Infectious disease for the house officer. J Clin Microbial 1978. Heineman HS. Health Lab Sci 1977. other than in the case of mucopu- 15. Schoutens E. A 5. New York: John Wiley and Sons. ed. Nasr FL. 14 1: 165-7 1. Beam TR. Dorn GL. DeKoster JP. ganism. Stool EW. orni- specimen collection as a means of improving thosis. Barry AL.