Specimen Collection: Sputum - CE/NCPD

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Bronchospasm or laryngospasm, as a result of suctioning, can be severe and prolonged, and, in some cases, can be life-threatening without intervention.

OVERVIEW

Sputum is produced by cells that line the respiratory tract. Although production is minimal in the healthy patient, disease processes can increase the amount or change the character of sputum. Examination of sputum aids in the diagnosis and treatment of many conditions such as bronchitis, bronchiectasis, tuberculosis (TB), pneumonia and pulmonary abscess, or lung cancer.^{undefined#ref2">2}

In many cases, suctioning is indicated to collect sputum from a patient who cannot spontaneously produce a sample for laboratory analysis. Suctioning may provoke violent coughing, induce vomiting, and result in aspiration of stomach contents. Suctioning may also induce constriction of the pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may cause hypoxia or vagal overload, causing cardiopulmonary compromise and an increase in intracranial pressure.

Sputum for cytology, culture and sensitivity, and acid-fast bacilli (AFB) are three major types of sputum specimens.² Cytologic or cellular examination of sputum may identify aberrant cells or cancer. Sputum collected for culture and sensitivity testing can be used to identify specific microorganisms and determine which antibiotics are the most sensitive. The AFB smear is used to support a diagnosis of TB. A definitive diagnosis of TB also requires a sputum culture and sensitivity.²

Regardless of which sputum test is ordered; a sputum specimen should be collected first thing in the morning due to a greater accumulation of bronchial secretions overnight.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Explain to the patient how and why the sputum specimen is being collected.
Explain to the patient the need to obtain a specimen that is not contaminated with saliva or oropharyngeal secretions.
Explain to the patient the difference between oropharyngeal secretions and sputum.
Instruct the patient not to clean teeth or use mouthwash before collecting an AFB specimen because this may kill the bacteria needed for the specimen.
Demonstrate the proper chest splinting technique for a postoperative patient or a patient with a weak cough.
If an aerosol treatment is indicated, explain the purpose and inform the patient that the aerosol treatment will stimulate coughing and sputum expectoration.
Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

Perform hand hygiene before patient contact. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Check the practitioner’s orders for the type of sputum analysis and specifications (e.g., amount of sputum, number of specimens, time of collection, method to obtain).
Assess the patient’s level of understanding of the procedure and its purpose.
Determine when the patient last ate a meal or had a tube feeding.
Rationale: Suctioning or coughing up secretions can trigger the gag reflex. If a patient has recently eaten, this may also trigger vomiting.
Assess the patient’s respiratory status, including respiratory rate, depth, pattern, and color of mucous membranes, before obtaining the sputum specimen.

Preparation

Gather the necessary supplies, including the appropriate PPE.
Take airborne precautions when caring for a patient who is suspected of having TB or other airborne transmissible diseases.
Determine the patient’s ability to assist with the collection of the sputum specimen.
Provide privacy for the patient.
Position the patient in the high Fowler or semi-Fowler position for specimen collection.
Rationale: The high Fowler or semi-Fowler position promotes full lung expansion and facilitates the ability to cough.
Instruct a patient who has an operative or invasive incision or localized area of discomfort to place hands firmly over the affected area or to place a pillow over the affected area (as applicable).

PROCEDURE

Sputum Collection Using the Coughing and Expectorating Method

Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Verify the correct patient using two identifiers.
Explain the procedure and ensure that the patient agrees to treatment.
Provide the patient with the appropriate sterile container for specimen collection. Instruct the patient not to touch the inside of the container.
Rationale: Touching the inside of the sterile container may compromise the laboratory test results.
Instruct the patient to take a slow deep breath and to cough after a full inhalation.
Rationale: Expectorant must come from the lungs. Saliva is not sputum.²
Instruct the patient to expectorate sputum directly into the sterile specimen container.
Instruct the patient to repeat coughing until a sufficient quantity, a minimum of 5 ml of sputum, is collected.²
Secure the top on the specimen container tightly.
Wipe any sputum present on the outside of the container with a disinfectant wipe.
Ensure that the container is tightly closed before wiping to prevent contaminating the specimen.
Offer tissues to the patient after expectoration. Dispose of the tissues in an appropriate waste receptacle.
Offer the patient mouth care, if desired.
In the presence of the patient, label the specimen per the organization’s practice.¹
Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

Sputum Collection Using Suctioning

Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Verify the correct patient using two identifiers.
Explain the procedure and ensure that the patient agrees to treatment.
Prepare the suction machine or device and ensure that the suction source is functioning properly.
Open a new flexible sterile suction catheter.
Connect the flexible suction tubing to the rubber tubing on the sputum trap using aseptic technique.
Open and pour 0.9% sodium chloride solution or a water-soluble lubricant into the sterile tray of the suction catheter.
Remove gloves, perform hand hygiene, and don sterile gloves.
Apply 0.9% sodium chloride solution or water-soluble lubricant to the end of the flexible suction catheter.
Instruct the patient to breathe normally during the suctioning procedure to prevent hyperventilation. Explain to the patient that the catheter may trigger the cough reflex.
Rationale: Entering the larynx and trachea triggers the cough reflex.
Gently insert the tip of the suction catheter through the patient’s nasopharynx, endotracheal tube, or tracheostomy tube without applying suction.
Rationale: Inserting the tip of the flexible suction catheter without applying suction minimizes hypoxia and trauma to the patient’s airway as the catheter is inserted.
Advance the flexible suction catheter into the trachea gently and quickly.
Apply suction to the catheter by placing the thumb of the nondominant hand over the suction port of the flexible suction catheter or by depressing the suction button of the sleeved suction catheter for 10 to 15 seconds as the patient coughs.³ Collect 5 to 10 ml of sputum.²
Apply suction only while withdrawing the catheter from the insertion site. Maintain sterility when suctioning the endotracheal or tracheostomy tube site.
Limit the duration of each suction pass to less than 15 seconds and limit the number of passes to a maximum of three to help minimize hypoxia, airway trauma, and cardiac arrhythmias.³

If the patient becomes hypoxic during the suctioning procedure, discontinue suctioning immediately and provide supplemental oxygen.
Release the suction and withdraw the suction catheter.
Rationale: Suction can damage mucosa if applied during withdrawal.
Turn off the suction source.
Evaluate the patient immediately after the suctioning procedure. Note if the patient has any shortness of breath or signs of hypoxia.
Detach the suction catheter from the specimen trap. Dispose of the flexible suction catheter in an appropriate receptacle.
Detach the suction tubing and connect the rubber tubing on the sputum trap to the plastic adapter (Figure 1).
Wipe off any sputum present on the outside of the sputum trap with a disinfectant wipe.
Ensure that the sputum trap is tightly sealed before wiping to prevent contaminating the specimen.
Offer tissues to the patient after suctioning. Dispose of the tissues in an appropriate waste receptacle.
Offer the patient mouth care, if desired.
In the presence of the patient, label the specimen per the organization’s practice.¹
Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

MONITORING AND CARE

Observe and monitor the patient’s respiratory status throughout the procedure, especially during suctioning.
Rationale: Excessive coughing or prolonged suctioning can alter the patient’s respiratory pattern and cause hypoxia.
Observe the patient for anxiety or discomfort.
Rationale: The procedure can be uncomfortable. Anxiety may develop if the patient becomes short of breath.
Continue to observe the character of sputum, noting the color, consistency, volume, viscosity, and presence of blood.
Rationale: Abnormal sputum characteristics may indicate disease entities.

Report unusual sputum characteristics or changes in the characteristics of the sputum to the practitioner.

EXPECTED OUTCOMES

Patient’s respirations are the same rate and character as before the procedure.
Patient is relaxed and able to answer questions.
Sputum is not contaminated by saliva or oropharyngeal flora.
Patient maintains adequate oxygen saturation levels.
Patient tolerates procedure without pain or discomfort.

UNEXPECTED OUTCOMES

Patient becomes hypoxic.
Patient has increased respiratory rate and effort.
Patient feels short of breath.
Oxygen saturation levels drop after procedure and do not improve after procedure completed.
Patient remains anxious or complains of discomfort from the suction catheter.
Inadequate amount of sputum is collected.
Specimen contains blood, pathogenic organisms, or abnormal cells.
Patient complains of pain when coughing to produce sputum.

DOCUMENTATION

Method used to obtain specimen
Date and time of collection
Type of test ordered
Characteristics of sputum specimen
Patient’s tolerance of procedure
Unexpected outcomes and related interventions
Education

PEDIATRIC CONSIDERATIONS

Take the time to develop rapport and trust with a pediatric patient before beginning any invasive procedure. Include the family; if the family demonstrates trust, the patient will be less anxious.
Take the time to include a child life specialist or use an age-appropriate distraction to manage pain and anxiety.
Use a developmentally appropriate approach and explanation of the procedure.
Encourage the family to remain present during the procedure.
Encourage the family to participate in the procedure at whatever level is comfortable.
A young child’s head and arms may need to be stabilized during suctioning.
Catheter size should be appropriate for the child’s age and size. Using a length-based resuscitation tape can be used to determine the appropriate size.

REFERENCES

Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved October 31, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)
Pagana, K.D., Pagana, T.J., Pagana, T.N. (2022). Chapter 7: Microbiologic studies and associated testing. In Mosby’s manual of diagnostic and laboratory tests (7th ed., pp. 661-746). St. Louis: Elsevier.
Stacy, K.M. (2022). Chapter 20: Pulmonary therapeutic management. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (9th ed., pp. 499-529). St. Louis: Elsevier.

Adapted from Perry, A.G. and others (Eds.). (2022). Clinical nursing skills & techniques (10th ed.). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)
Published: December 2023