the main methods of functional diagnostics of pulmonary diseases
TRANSCRIPT
The main methods of The main methods of functional diagnostics functional diagnostics of pulmonary diseasesof pulmonary diseases
Obtaining a sputum Obtaining a sputum samplesample
Mouth should be free of foreign objects Mouth should be free of foreign objects Remove food, gum, or Remove food, gum, or TobaccoTobacco Remove dentures Remove dentures
Early morning specimen is best Early morning specimen is best Induce sputum if necessary Induce sputum if necessary
Nebulized hypertonic saline or Nebulized hypertonic saline or distilled water distilled water
Chest percussion Chest percussion Postural drainage Postural drainage
CoughCough into sterile specimen cup into sterile specimen cup
Special Circumstances Special Circumstances TuberculosisTuberculosis suspected suspected
Sputum collected in negative pressure room Sputum collected in negative pressure room Early morning gastric aspirate Early morning gastric aspirate Bronchoscopy with bronchial lavage Bronchoscopy with bronchial lavage
Anaerobic culture specimen Anaerobic culture specimen Transtracheal aspiration Transtracheal aspiration ThoracentesisThoracentesis Direct lung puncture Direct lung puncture
Viral Culture Specimens Viral Culture Specimens Patient gargles and expectorates with Patient gargles and expectorates with
nutrient broth nutrient broth Nasopharyngeal swab transported in viral Nasopharyngeal swab transported in viral
medium medium
Preparation of Sputum for Preparation of Sputum for Lab Lab
Fixation of sputum for cytology (prevents air drying) Fixation of sputum for cytology (prevents air drying) Patient expectorates into jar of 70% Patient expectorates into jar of 70% EthanolEthanol Spread fresh sputum on slide and spray pap fixative Spread fresh sputum on slide and spray pap fixative
Culture specimen transport to lab Culture specimen transport to lab Sputum Gram StainSputum Gram Stain assesses sample for adequacy assesses sample for adequacy Anaerobic cultures transported in air tight container Anaerobic cultures transported in air tight container
Transport to lab for immediate plating Transport to lab for immediate plating Aerobic culture specimen Aerobic culture specimen
Bring to lab as quickly as possible Bring to lab as quickly as possible Refrigerate specimen if transport delayed Refrigerate specimen if transport delayed Consider washing specimen of oral flora Consider washing specimen of oral flora
Rinse several times with saline Rinse several times with saline Discard supernatant (non-viscous Discard supernatant (non-viscous SalivaSaliva) )
TuberculosisTuberculosis culture culture May be stored at room temperature for up to 48 May be stored at room temperature for up to 48
hour hour
Sputum Gross ExamSputum Gross Exam
Estimate daily volume of Estimate daily volume of SputumSputum
Small amounts Small amounts Lung AbscessLung Abscess PneumoniaPneumonia TuberculosisTuberculosis
Copious amounts (>200 cc/day) Copious amounts (>200 cc/day) BronchiectasisBronchiectasis Bronchopleural FistulaBronchopleural Fistula
Sputum Color Sputum Color
Bloody SputumBloody Sputum ( (HemoptysisHemoptysis) ) Rusty Rusty SputumSputum (Prune-juice) (Prune-juice)
Pneumococcal PneumoniaPneumococcal Pneumonia Purulent SputumPurulent Sputum (yellow, green, (yellow, green,
dirty-gray) dirty-gray) Color alone does not Color alone does not
distinguish bacterial distinguish bacterial infection infection
Sputum TurbiditySputum Turbidity
Frothy Frothy SputumSputum (air bubbles, (air bubbles, HemoglobinHemoglobin) ) Pulmonary edema Pulmonary edema
Foamy, clear material Foamy, clear material SalivaSaliva Nasal secretions Nasal secretions
Sputum Viscosity Sputum Viscosity Bloody Gelatinous Bloody Gelatinous SputumSputum (Currant-Jelly) (Currant-Jelly)
KlebsiellaKlebsiella PneumoniaPneumonia Pneumococcal PneumoniaPneumococcal Pneumonia
Stringy Mucoid Stringy Mucoid SputumSputum (may also appear (may also appear frothy) frothy)
Follows Follows AsthmaAsthma exacerbation exacerbation Cloudy, mucoid Cloudy, mucoid SputumSputum
Chronic BronchitisChronic Bronchitis Three layered appearance (stagnant, Three layered appearance (stagnant,
Purulent SputumPurulent Sputum) ) BronchiectasisBronchiectasis Lung AbscessLung Abscess
Sputum with Feculent Sputum with Feculent OdorOdor
Anaerobic infection Anaerobic infection BronchiectasisBronchiectasis
Sputum Sputum MicroscopyMicroscopy
Assessing Sputum Sample Assessing Sputum Sample QualityQuality
Ideal Ideal SputumSputum Sample for Culture Sample for Culture Under 10 squamous epithelial cell Under 10 squamous epithelial cell
per low power field per low power field Many Many NeutrophilNeutrophils present (>5 per s present (>5 per
high power field) high power field) Bronchial epithelial cells present Bronchial epithelial cells present Alveolar Alveolar MacrophageMacrophages may be present s may be present
Inadequate Inadequate SputumSputum Sample Sample Over 25 squamous epithelial Over 25 squamous epithelial
cells/LPM cells/LPM
Sputum Sample Sputum Sample Preparation Preparation
Pull strand or plug of Pull strand or plug of SputumSputum onto slide onto slide
Consider buffered crystal Consider buffered crystal violet to stain cells violet to stain cells
Apply cover slip Apply cover slip View under oil immersion View under oil immersion
Cytology Stains Cytology Stains No Stain No Stain
BlastomycosisBlastomycosis Cryptococcosis Cryptococcosis
Gram StainGram Stain Gram Positive BacteriaGram Positive Bacteria Candida Candida TuberculosisTuberculosis (weakly (weakly Gram PositiveGram Positive) ) NocardiaNocardia (weakly (weakly Gram PositiveGram Positive) )
Direct Fluorescent Direct Fluorescent AntibodyAntibody Staining Staining LegionellaLegionella
Wright stain or Giemsa Stain Wright stain or Giemsa Stain Intracellular organisms Intracellular organisms
Special Staining Special Staining Circumstances Circumstances
Acid-fast Mycobacteria Acid-fast Mycobacteria (Tuberculosis)(Tuberculosis)
Ziehl-Neelsen Stain (Red against blue Ziehl-Neelsen Stain (Red against blue background) background)
Kinyoun stain Kinyoun stain Less reliable than Ziehl-Neelsen stain Less reliable than Ziehl-Neelsen stain Results in quickly stained sample Results in quickly stained sample
Fluorochrome dyes (auramine, Fluorochrome dyes (auramine, rhodamine) rhodamine) Higher false positive rate than Ziehl-Higher false positive rate than Ziehl-
Neelsen stain Neelsen stain Assist greatly in identifying organisms Assist greatly in identifying organisms
Fungal OrganismsFungal Organisms
PAS staining or Methenamine PAS staining or Methenamine silver staining silver staining HistoplasmosisHistoplasmosis CoccidioidomycosisCoccidioidomycosis AspergillusAspergillus Mucor Mucor
KOH PreparationKOH Preparation
Microscopic findings Microscopic findings Caseous masses Caseous masses Dittrich's plugs Dittrich's plugs Curschmann's spirals (Curschmann's spirals (AsthmaAsthma) ) Charcot-Leyden Crystals (Charcot-Leyden Crystals (AsthmaAsthma) ) Bronchial casts Bronchial casts Concretions Concretions Broncholith Broncholith
Calcified particles as seen in Calcified particles as seen in BroncholithiasisBroncholithiasis Lung CancerLung Cancer cells cells
Central bronchus tumors Central bronchus tumors May require 4 samples to detect May require 4 samples to detect
EosinophilEosinophils (>5%): identified with Wright's Stain s (>5%): identified with Wright's Stain Allergy Allergy AsthmaAsthma
PneumoniaPneumonia
General General Lab Indications Lab Indications
Moderate or severe community Moderate or severe community acquired pneumonia acquired pneumonia
Patient with comorbid Patient with comorbid conditions conditions
Efficacy of Labs Efficacy of Labs No value in non-severe No value in non-severe
community acquired pneumonia community acquired pneumonia
SputumSputum Examination Examination
Tests Tests Sputum Gram StainSputum Gram Stain Sputum CultureSputum Culture
Efficacy of Efficacy of SputumSputum exam exam SputumSputum has low diagnostic has low diagnostic
yield in CAP yield in CAP Not recommended in Not recommended in
community acquired community acquired pneumonia pneumonia
Blood CultureBlood Culture
Indications Indications Not indicated unless severe Not indicated unless severe
disease disease Recommended by ATS in Recommended by ATS in
hospitalized CAP hospitalized CAP Efficacy Efficacy
Low sensitivity: Positive in Low sensitivity: Positive in only 5-10% of cases only 5-10% of cases
Does not predict severity or Does not predict severity or outcome outcome
Specific Testing with Specific Testing with reasonable efficacyreasonable efficacy
ChlamydiaChlamydia pneumonia pneumonia Rapid PCR (>30% Rapid PCR (>30% Test SensitivityTest Sensitivity) )
InfluenzaInfluenza Rapid Influenza TestRapid Influenza Test ( (InfluenzaInfluenza DFA) DFA)
Legionella pneumophilaLegionella pneumophila Rapid PCR of Rapid PCR of SputumSputum (80% (80%
Test SensitivityTest Sensitivity) ) Urinary antigen (>50% Urinary antigen (>50% Test SensitivityTest Sensitivity) )
Mycoplasma pneumoniaeMycoplasma pneumoniae Rapid PCR of Rapid PCR of SputumSputum (>30% (>30%
Test SensitivityTest Sensitivity) )
Chronic BronchitisChronic Bronchitis
Labs Labs Arterial Blood GasArterial Blood Gas (ABG) (ABG)
Markedly reduced arterial pO2 Markedly reduced arterial pO2 Elevated arterial pCO2 (40-50 mmHg) Elevated arterial pCO2 (40-50 mmHg)
Pulmonary Function TestPulmonary Function Tests s Residual VolumeResidual Volume increased increased FEV1 decreased FEV1 decreased FEV1/FVC decreased FEV1/FVC decreased FEF 25-75 (mid-flows) decreased FEF 25-75 (mid-flows) decreased Diffusion capacity (Diffusion capacity (DLCODLCO) near normal ) near normal
Bronchiectasis Bronchiectasis
Labs: Sputum Labs: Sputum SputumSputum forms layers on standing forms layers on standing
Top: Mucus Top: Mucus Middle: Clear fluid Middle: Clear fluid Bottom: Pus Bottom: Pus
Sputum Culture not diagnostic Sputum Culture not diagnostic (mixture of organisms) (mixture of organisms)
Fungal Culture Fungal Culture
Lung AbscessLung Abscess
Labs Labs Sputum examination Sputum examination
Microscopy Microscopy Gram Stain Gram Stain Mycobacterial stains Mycobacterial stains Fungal stains Fungal stains
Sputum layers on standing Sputum layers on standing Sputum Cultures are usually not Sputum Cultures are usually not helpful helpful
Complete Blood Count Complete Blood Count Leukocytosis Leukocytosis
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