Cytology, Sputum

Cytology, Sputum

Synonym/acronym: N/A.

Common use

To identify cellular changes associated with neoplasms or organisms that result in respiratory tract infections, such as Pneumocystis jiroveci (formerly P. carinii).

Specimen

Sputum (10 to 15 mL) collected on three to five consecutive first-morning, deep-cough expectorations.

Normal findings

(Method: Macroscopic and microscopic examination) Negative for abnormal cells, fungi, ova, and parasites.

Description

Cytology is the study of the origin, structure, function, and pathology of cells. In clinical practice, cytological examinations are generally performed to detect cell changes resulting from neoplastic or inflammatory conditions. Sputum specimens for cytological examinations may be collected by expectoration alone, by suctioning, by lung biopsy, during bronchoscopy, or by expectoration after bronchoscopy. A description of the method of specimen collection by bronchoscopy and biopsy is found in the monograph titled “Biopsy, Lung.”

This procedure is contraindicated for

    N/A

Indications

  • Assist in the diagnosis of lung cancer
  • Assist in the identification of Pneumocystis jiroveci (formerly P. carinii) in persons with AIDS
  • Detect known or suspected fungal or parasitic infection involving the lung
  • Detect known or suspected viral disease involving the lung
  • Screen cigarette smokers for neoplastic (nonmalignant) cellular changes
  • Screen patients with history of acute or chronic inflammatory or infectious lung disorders, which may lead to benign atypical or metaplastic changes

Potential diagnosis

(Method: Microscopic examination) The method of reporting results of cytology examinations varies according to the laboratory performing the test. Terms used to report results may include negative (no abnormal cells seen), inflammatory, benign atypical, suspect for neoplasm, and positive for neoplasm.

Positive findings in:

  • Infections caused by fungi, ova, or parasites
  • Lipoid or aspiration pneumonia, as seen by lipid droplets contained in macrophages
  • Neoplasms
  • Viral infections and lung disease

Critical findings

  • Identification of malignancy

  • Note and immediately report to the health-care provider (HCP) positive results and related symptoms.

  • It is essential that a critical finding be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. Notification processes will vary among facilities. Upon receipt of the critical value the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, Hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical value, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

  • If the patient becomes hypoxic or cyanotic, remove catheter immediately and administer oxygen.

  • If patient has asthma or chronic bronchitis, watch for aggravated bronchospasms with use of normal saline or acetylcysteine in an aerosol.

Interfering factors

  • Improper specimen fixation may be cause for specimen rejection.
  • Improper technique used to obtain bronchial washing may be cause for specimen rejection.
  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this test can assist in identification of the organism causing infection.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
  • Obtain a history of the patient’s immune and respiratory systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Note any recent procedures that can interfere with test results.
  • Review the procedure with the patient. If the laboratory has provided a container with fixative, instruct the patient that the fixative contents of the specimen collection container should not be ingested or otherwise removed. Instruct the patient not to touch the edge or inside of the specimen container with the hands or mouth. Inform the patient that three samples may be required, on three separate mornings, either by passing a small tube (tracheal catheter) and adding suction or by expectoration. The time it takes to collect a proper specimen varies according to the level of cooperation of the patient and the specimen collection procedure. Address concerns about pain related to the procedure. Atropine is usually given before bronchoscopy examinations to reduce bronchial secretions and to prevent vagally induced bradycardia. Meperidine (Demerol) or morphine may be given as a sedative. Lidocaine is sprayed in the patient’s throat to reduce discomfort caused by the presence of the tube.
  • Reassure the patient that he or she will be able to breathe during the procedure if specimen is collected via suction method. Ensure that oxygen has been administered 20 to 30 min before the procedure if the specimen is to be obtained by tracheal suctioning.
  • Assist in providing extra fluids, unless contraindicated, and proper humidification to loosen tenacious secretions. Inform the patient that increasing fluid intake before retiring on the night before the test aids in liquefying secretions and may make it easier to expectorate in the morning. Also explain that humidifying inspired air also helps to liquefy secretions.
  • Assist with mouth care (brushing teeth or rinsing mouth with water), if needed, before collection so as not to contaminate the specimen by oral secretions.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during and after the procedure.
  • For specimens collected by suctioning or expectoration without bronchoscopy, there are no food, fluid, or medication restrictions unless by medical direction.
  • Instruct the patient to fast and refrain from taking liquids from midnight the night before if bronchoscopy or biopsy is to be performed. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the bronchoscopy or biopsy procedure and before administering any medications.

Intratest

  • Potential complications:

  • Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners), bronchospasm, pneumothorax, or hemoptysis.

  • Ensure that the patient has complied with dietary restrictions; assure that food and liquids have been restricted for at least 6 to 8 hr prior to the procedure.
  • Have patient remove dentures, contact lenses, eyeglasses, and jewelry. Notify the HCP if the patient has permanent crowns on teeth. Have the patient remove clothing and change into a gown for the procedure.
  • Have emergency equipment readily available. Keep resuscitation equipment on hand in the case of respiratory impairment or laryngospasm after the procedure.
  • Avoid using morphine sulfate in those with asthma or other pulmonary disease. This drug can further exacerbate bronchospasms and respiratory impairment.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Assist the patient to a comfortable position, and direct the patient to breathe normally during the beginning of the general anesthesia and to avoid unnecessary movement during the local anesthetic and the procedure. Instruct the patient to cooperate fully and to follow directions.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate collection container with the corresponding patient demographics, date and time of collection, and any medication the patient is taking that may interfere with test results (e.g., antibiotics). Cytology specimens may also be expressed onto a glass slide and sprayed with a fixative or 95% alcohol.

    • Bronchoscopy

  • Record baseline vital signs.
  • The patient is positioned in relation to the type of anesthesia being used. If local anesthesia is used, the patient is seated, and the tongue and oropharynx are sprayed and swabbed with anesthetic before the bronchoscope is inserted. For general anesthesia, the patient is placed in a supine position with the neck hyperextended. After anesthesia, the patient is kept in supine or shifted to side-lying position, and the bronchoscope is inserted. After inspection, the samples are collected from suspicious sites by bronchial brush or biopsy forceps.

    • Expectorated Specimen

  • Ask the patient to sit upright, with assistance and support (e.g., with an overbed table) as needed.
  • Ask the patient to take two or three deep breaths and cough deeply. Any sputum raised should be expectorated directly into a sterile sputum collection container.
  • If the patient is unable to produce the desired amount of sputum, several strategies may be attempted. One approach is to have the patient drink two glasses of water, and then assume the position for postural drainage of the upper and middle lung segments. Effective coughing may be assisted by placing either the hands or a pillow over the diaphragmatic area and applying slight pressure.
  • Another approach is to place a vaporizer or other humidifying device at the bedside. After sufficient exposure to adequate humidification, postural drainage of the upper and middle lung segments may be repeated before attempting to obtain the specimen.
  • Other methods may include obtaining an order for an expectorant to be administered with additional water approximately 2 hr before attempting to obtain the specimen. Chest percussion and postural drainage of all lung segments may also be employed. If the patient is still unable to raise sputum, the use of an ultrasonic nebulizer (“induced sputum”) may be necessary; this is usually done by a respiratory therapist.

    • Tracheal Suctioning

  • Obtain the necessary equipment, including a suction device, suction kit, and Lukens tube or in-line trap.
  • Position the patient with head elevated as high as tolerated.
  • Put on sterile gloves. Maintain the dominant hand as sterile and the nondominant hand as clean.
  • Using the sterile hand, attach the suction catheter to the rubber tubing of the Lukens tube or in-line trap. Then attach the suction tubing to the male adapter of the trap with the clean hand. Lubricate the suction catheter with sterile saline.
  • Tell nonintubated patients to protrude the tongue and to take a deep breath as the suction catheter is passed through the nostril. When the catheter enters the trachea, a reflex cough is stimulated; immediately advance the catheter into the trachea and apply suction. Maintain suction for approximately 10 sec, but never longer than 15 sec. Withdraw the catheter without applying suction. Separate the suction catheter and suction tubing from the trap, and place the rubber tubing over the male adapter to seal the unit.
  • For intubated patients or patients with a tracheostomy, the previous procedure is followed except that the suction catheter is passed through the existing endotracheal or tracheostomy tube rather than through the nostril. The patient should be hyperoxygenated before and after the procedure in accordance with standard protocols for suctioning these patients.
  • Generally, a series of three to five early-morning sputum samples are collected in sterile containers.

    • General

  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
  • Promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet, as directed by the HCP. Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
  • Inform the patient that he or she may experience some throat soreness and hoarseness. Instruct patient to treat throat discomfort with lozenges and warm gargles when the gag reflex returns.
  • Monitor vital signs and compare with baseline values every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Emergency resuscitation equipment should be readily available if the vocal cords become spastic after intubation.
  • Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Observe/assess the patient for hemoptysis, difficulty breathing, cough, air hunger, excessive coughing, pain, or absent breathing sounds over the affected area. Report any symptoms to the HCP.
  • Evaluate the patient for symptoms indicating the development of pneumothorax, such as dyspnea, tachypnea, anxiety, decreased breathing sounds, or restlessness. A chest x-ray may be ordered to check for the presence of this complication.
  • Evaluate the patient for symptoms of empyema, such as fever, tachycardia, malaise, or elevated white blood cell count.
  • Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
  • Nutritional Considerations: Malnutrition is commonly seen in patients with severe respiratory disease for numerous reasons including fatigue, lack of appetite, and gastrointestinal distress. Adequate intake of vitamins A and C are also important to prevent pulmonary infection and to decrease the extent of lung tissue damage.
  • Recognize anxiety related to test results, and be supportive of impaired activity related to perceived loss of independence and fear of shortened life expectancy. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services. Provide contact information, if desired, for the American Lung Association (www.lungusa.org).
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient of smoking cessation programs, as appropriate. Inform the patient with abnormal findings of the importance of medical follow-up, and suggest ongoing support resources to assist in coping with chronic illness and possible early death. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include arterial/alveolar oxygen ratio, biopsy lung, blood gases, bronchoscopy, CBC, CT thoracic, relevant cultures (fungal, mycobacteria, sputum, throat, viral), gallium scan, Gram/acid-fast stain, lung perfusion scan, lung ventilation scan, MRI chest, mediastinoscopy, pleural fluid analysis, pulmonary function tests, and TB tests.
  • Refer to the Immune and Respiratory systems tables at the end of the book for related tests by body system.