Specimen Collection: Sputum (Pediatric) - CE/NCPD

ALERT

Suctioning may cause direct stimulation of vagal nerve fibers, especially in an infant.

OVERVIEW

Sputum is produced by cells lining the respiratory tract. Although production is minimal in the healthy state, disease states can increase the amount or change the character of sputum. Examination of sputum may aid with diagnosing and treating various conditions.

In many cases, suctioning is indicated to collect sputum from a young pediatric patient. Suctioning may also be necessary for pediatric patients with developmental delays, regardless of age. A cough can possibly be elicited by tickling the back of the patient’s throat with the suction catheter. In addition to direct stimulation of vagal nerve fibers, suctioning may provoke coughing, vomiting, and aspiration of stomach contents and induce pharyngeal, laryngeal, and bronchial muscle constriction. In pediatric patients with endotracheal (ET) or tracheostomy tubes, sputum is easily aspirated from the trachea. Adolescents and older pediatric patients are usually able to produce a sputum specimen by coughing if they are given very clear instructions.

Sputum for cytology, culture and sensitivity, and acid-fast bacilli (AFB) are the three major types of sputum specimens. Cytologic or cellular examination of sputum may identify aberrant cells or cancer. The most common types of diagnostic tests performed on sputum specimens include respiratory syncytial virus, influenza A and B, parainfluenza, rhinovirus, and enterovirus. Sputum collected for culture and sensitivity testing can be used to identify specific microorganisms to determine which antibiotics are the most sensitive. The AFB smear is used to support a diagnosis of tuberculosis (TB). A definitive diagnosis of TB also requires a sputum culture and sensitivity test.

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.
• For an older pediatric patient, demonstrate effective coughing techniques versus clearing of the throat.
• Demonstrate the splinting technique for a patient with abdominal or thoracic incisions.
• Explain to the patient and family the purpose of avoiding the use of mouthwashes and toothpaste before sputum expectoration.
• If an aerosol treatment is indicated, teach the patient and family the purpose of the procedure, explaining that it stimulates coughing and sputum expectoration.
• Instruct the patient and family to avoid contaminating the outside of the specimen cup to reduce the risk of spreading infection.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. 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 of obtaining specimens) and initiate appropriate isolation precautions until the results are obtained.
5. Assess the patient’s ability to cough and expectorate a specimen.
6. Determine when the patient last ate or had a tube feeding. Suctioning or coughing up secretions can trigger the gag reflex. If the patient has recently eaten, this may also trigger vomiting.
7. Determine the type of assistance the patient needs to obtain a specimen.
8. Assess the patient’s respiratory status, including respiratory rate, depth, and pattern, and the color of mucous membranes.
9. Assess the patient’s and family’s understanding of the reasons for and the risks and benefits of the procedure.

Preparation

1. 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.
2. Demonstrate deep breathing and expectoration.

   Stress the importance of deep coughing and of not clearing the throat if the patient is expectorating sputum. Have a health care team member secure the patient’s head and hands as needed if suctioning will be used to obtain a specimen.

3. For the collection of an expectorated specimen, ensure that the patient rinses the mouth or brushes teeth with water, as developmentally appropriate.

   Ensure that the patient does not use mouthwash or toothpaste because they may decrease the viability of the microorganisms and alter the culture results.

4. Position the patient appropriately, depending on the specimen collection method.
   1. To collect the specimen via coughing and expectoration, position the patient in the semi-Fowler position, sitting on the side of the bed, in a chair, or standing.
   2. To collect the specimen using suction, position the patient in the high Fowler or semi-Fowler position and allow the patient to sit in a family member’s or the assistant’s lap, if possible.

      Rationale: The semi-Fowler position promotes full lung expansion and aids the ability to cough.

PROCEDURE

Sputum Collection Using the Coughing and Expectorating Method

1. Perform hand hygiene and don gloves, gown, mask, and eye protection or face shield. If necessary, ensure that an assistant is available and wearing appropriate PPE.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Provide the patient with the specimen container (e.g., sputum trap) or have the assistant hold the container. Instruct the patient or family member not to touch the inside of the container.
5. 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.^{undefined#ref3">3}

6. Instruct the patient to expectorate sputum directly into the specimen container.
7. Instruct the patient to repeat coughing until a sufficient quantity (a minimum of 5 ml of sputum) is collected.³
8. Secure the top on the specimen container tightly.
9. Offer tissues after the patient expectorates. Dispose of the tissues in an emesis basin or appropriate waste receptacle.
10. Wipe off any sputum present on the outside of the container with a disinfectant wipe.

    Ensure that the container is tightly closed before wiping to prevent contamination of the specimen.

11. Offer the patient oral care, if desired.
12. Label the specimen in the presence of the patient.²
13. Place the labeled specimen in a biohazard bag and transport it to the laboratory.
14. Discard supplies, remove PPE, and perform hand hygiene.
15. Document the procedure in the patient’s record.

Sputum Collection Using Suction

1. 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.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Prepare the suction machine or device and ensure that the suction source is functioning properly.
   1. Ensure that the proper size suction catheter is used based on the patient’s size and the catheter’s comfortable fit in the nares.
   2. Set the vacuum regulator between 80 and 100 mm Hg (recommended for infants and children).¹
5. Connect the suction tubing to the adapter on the sputum trap.
6. If using a sleeved suction catheter, remove the suction tubing from the end of the catheter and connect it to the sputum trap.

   Rationale: Connecting the suction tubing to the sputum trap establishes suction that passes through the sputum trap to aspirate a specimen.

7. Remove gloves, perform hand hygiene, and don clean gloves, gown, mask, and eye protection or face shield. Don sterile gloves if a sterile suction catheter will be used.

   Rationale: The tracheobronchial tree is a sterile body cavity. Sterile gloves allow for manipulating the suction catheter without contaminating it.

   Sterile gloves are not required if a sleeved suction catheter is used.

8. Connect the regular sterile suction catheter or the end of the sleeved suction catheter to the rubber tubing on the sputum trap.

   Rationale: Connecting the sterile suction catheter or the sleeved suction catheter to the rubber tubing on the sputum trap allows aspirated sputum to go directly to the trap instead of to the suction tubing.

9. Apply a small amount of sterile, water-soluble lubricant to the end of the suction catheter if suctioning through the nasopharynx.
10. Instruct the patient to breathe normally during suctioning to prevent hyperventilation. Explain that the patient may cough.
11. Have the assistant position the patient so that the assistant has control of the patient’s head and hands.
12. Instruct the patient to cough before the procedure begins, if developmentally appropriate.

    Rationale: Having the patient cough allows secretions to gather and loosen before they are suctioned with the catheter.

13. Gently insert the tip of the suction catheter through the nasopharynx, the ET tube, or tracheostomy tube without applying suction.

    Rationale: Inserting the catheter without applying suction decreases the chances of trauma to the mucosa.

    Advance the suction catheter only to the point of resistance in the naris.

14. Advance the catheter into the trachea gently and quickly.

    Rationale: Entering the larynx and trachea triggers the cough reflex.

15. Apply suction by placing the thumb of the nondominant hand over the suction port of the regular suction catheter or by depressing the suction button of the sleeved suction catheter for 5 seconds as the patient coughs.¹

    Rationale: Rotating the catheter during withdrawal minimizes mucosal damage.

16. When obtaining the sputum specimen, apply suction only while withdrawing the catheter from the insertion site. Maintain sterility when suctioning the ET or tracheostomy tube site.

    Limit the duration of each suction pass to less than 5 seconds and limit the number of passes to a maximum of three to help minimize hypoxemia, airway trauma, and cardiac arrhythmias.¹

    If the patient becomes hypoxic during the procedure, discontinue the procedure immediately and provide supplemental oxygen, tactile stimulation, and positive pressure ventilation.

17. Release the suction after the sputum specimen is obtained and withdraw the catheter.

    Rationale: Suction can damage mucosa if it is applied during withdrawal.

    If another suction pass is needed, give the patient 30 to 60 seconds to recover.¹

18. Turn off the vacuum regulator.
19. Evaluate the patient immediately after the procedure. Observe for any shortness of breath or signs of hypoxemia.
20. Detach the catheter from the specimen trap.
    1. Dispose of the catheter in the appropriate receptacle if using a regular suction catheter.
    2. Reconnect the suction tubing to the end of the catheter if using a sleeved suction catheter.
21. Detach the suction tubing and connect the rubber tubing on the sputum trap to the plastic adapter (Figure 1).
22. Wipe off any sputum present on the outside of the container with a disinfectant wipe.

    Ensure that the sputum trap is tightly sealed before wiping to prevent contaminating the specimen.

23. Offer the patient oral care, if desired.
24. Label the specimen in the presence of the patient.²
25. Place the labeled specimen in a biohazard bag and transport it to the laboratory.
26. Discard supplies, remove PPE, and perform hand hygiene.
27. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Observe and monitor the patient’s respiratory status throughout the procedure, especially during suctioning.

   Rationale: Excessive coughing or prolonged suctioning can alter the respiratory pattern and cause hypoxemia.

2. Allow the family to comfort the patient. If the family is not available, have a health care team member comfort the patient.

   Rationale: The procedure may be uncomfortable and scary for a patient.

3. Continue to observe the character of the sputum, including color, consistency, odor, volume, and viscosity, and look for blood.

   Rationale: Abnormal sputum characteristics may indicate disease entities.

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

4. Refer to the laboratory reports for test results.
   1. Report abnormal findings to the practitioner.
   2. Initiate appropriate isolation techniques if an AFB sputum culture is positive.

      Rationale: An AFB culture indicates whether abnormal cells or microorganisms are in sputum.

EXPECTED OUTCOMES

• Patient’s respirations are the same rate and character as before procedure.
• Adequate sputum sample is obtained.
• 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, requires increased respiratory rate and effort, or feels short of breath.
• Oxygen saturation levels drop after procedure and do not improve after procedure is completed.
• Patient experiences arrhythmia after suctioning.
• Patient remains anxious or expresses discomfort resulting from suction catheter.
• Specimen contains saliva.
• Specimen contains blood, pathogenic organisms, or abnormal cells.
• Inadequate amount of sputum is collected.
• Patient complains of or exhibits pain when coughing to produce sputum.
• Nasopharynx mucosal lining is damaged or edematous.

DOCUMENTATION

• Method used to obtain specimen
• Date and time of collection, type of test ordered, and laboratory receiving specimen
• Characteristics of sputum specimen
• Patient’s tolerance of procedure
• Isolation precautions in use
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Anderson, C.E., Herring, R.A. (2022). Chapter 20: Pediatric nursing interventions and skills. In M.J. Hockenberry, C.C. Rodgers, D. Wilson (Eds.), Wong’s essentials of pediatric nursing (11th ed., pp. 551-618). St. Louis: Elsevier.
2. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved November 25, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf (Level VII)
3. 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.

ADDITIONAL READINGS

Booth, L.D. and others (2021). Culture ordering for patients with new-onset fever: A survey of pediatric intensive care unit clinician practices. Pediatric Quality and Safety, 6(5), Art. No.: e463. doi:10.1097/pq9.0000000000000463

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: Sarah A. Martin, DNP, MS, CPNP-AC/PC, CCRN

Published: January 2024