evidence & practice / clinical investigations series

RESPIRATORY CARE

Sputum collection and analysis:

what the nurse needs to know
Myatt R (2017) Sputum collection and analysis: what the nurse needs to know. Nursing Standard. 31, 27, 40-43.
Date of submission: 19 July 2015; date of acceptance: 11 May 2016. doi: 10.7748/ns.2017.e10228

Rebecca Myatt Rationale and key points

Nurse case manager Sputum is the term used to describe mucus that has been expectorated. It consists of secretions
(thoracic surgery), Guy’s and other matter that has been coughed up from the lungs and large airways. This article
Hospital, Guy’s and St informs nurses about how and why sputum collection and analysis are undertaken.
Thomas’ NHS Foundation »» Sputum is always considered abnormal, because healthy people swallow bronchial secretions.
Trust, London, England »» Sputum analysis is important, because it enables diagnosis of conditions such as pneumonia,
tuberculosis, lung abscess and lung cancer.
Correspondence »» The nurse should record the colour, amount and consistency of the sputum collected. They
Rebecca.Myatt@gstt. should send the specimen to the laboratory for analysis without delay to ensure accurate
nhs.uk results.

Conflict of interest Keywords

None declared airway, clinical investigations, lungs, mucus, respiratory care, respiratory system, sputum,
sputum collection, sputum sample
Peer review
This article has been
subject to external
double-blind peer Learning outcomes (Figure 1) (Dougherty and Lister 2015).
review and checked After reading the article you should be Sputum analysis also enables a patient’s
for plagiarism using able to: sensitivity to antibiotics to be ascertained,
automated software »» Understand the clinical importance of so that accurate treatment can be initiated
sputum collection and analysis. promptly (Randle et al 2009).
Contributing to the »» Demonstrate the correct procedure for
clinical investigations collecting sputum samples. Related physiology
series »» Explain the rationale for each stage of Below the vocal cords, the structures
To suggest an article for sputum collection. of the respiratory system are lined
the series, please email with pseudostratified ciliated columnar
investigations@rcni.com Sputum production epithelium (Marieb 2011). Cilia are
with a synopsis of your Sputum is the term used to describe mucus small hairs that occur in large numbers
idea. from the lungs that has been expectorated in the lining of the respiratory tract that
(Hough 2014). It consists of secretions continually propel mucus, loaded with
Online and other matter that has been coughed dust particles and other debris, towards the
For related articles visit up from the lungs and large airways pharynx to prevent it from accumulating
the archive and search (Randle et al 2009). In healthy people, in the lungs. Goblet cells, which secrete
using the keywords. bronchial secretions are swallowed; mucus, are interspersed between the
Guidelines on writing for therefore, sputum is always considered ciliated cells. Mucus is moved up and
publication are available abnormal (Hough 2014). Common causes out of the larynx by a process known as
at: journals.rcni.com/r/ of sputum production are listed in Table 1. mucociliary clearance (Marieb 2011).
author-guidelines Sputum analysis is an important There are no cells that produce cilia or
investigation because it enables diagnosis mucus in the bronchioles; therefore, any
of conditions such as pneumonia, airborne debris found at or below this
tuberculosis, lung abscess and lung cancer level is normally removed by large white

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blood cells known as macrophages. These
are located in the alveoli, and surround
and digest foreign matter and dead tissue
cells in a process known as phagocytosis
(Marieb 2011). Macrophages efficiently
remove large numbers of infectious
microorganisms that are carried into the
alveoli, leaving the alveolar surfaces sterile.
Dead and dying macrophages are carried
passively by the cilia, which move together
in a wave-like motion, transporting debris
in one direction across cell surfaces, away
from the alveoli, towards the pharynx.
This prevents debris from accumulating in
the lungs. By this process, the body clears
and swallows more than two million dust
particles per hour (Marieb 2011).
In certain conditions, such as inflammation
associated with asthma or infection, the
amount of mucus produced increases. It
may overwhelm the mucociliary clearance
process, or irritate the airways and cause
the patient to cough. In this case, the mucus
is expectorated as sputum. Lower airway
secretions that are not cleared provide an
ideal environment for bacterial growth
(Dougherty and Lister 2015).
–– Sputum specimen collection container.
–– Clinical waste bin.
»» The nurse should explain the procedure
to the patient and obtain verbal consent.
They should ensure privacy, because
sputum production is potentially
embarrassing for the patient.
»» The nurse should assist the patient to
an upright sitting position. This enables
maximum lung expansion and promotes
a deep cough (Hough 2014).
»» The nurse should be aware that early-
morning sputum samples are preferred,
because they contain a high bacterial
TABLE 1. Causes and characteristics of sputum
Common cause
Bronchiectasis
Lung cancer
Pulmonary tuberculosis
Lung abscess
Disclaimer
Please note that
information provided
by Nursing Standard is
not sufficient to make
the reader competent to
perform the task. All clinical
skills should be formally
assessed by a nurse
educator or mentor. It is
the nurse’s responsibility
to ensure their practice
remains up to date and
reflects the latest evidence
Characteristics of sputum
Purulent, yellow or green, malodorous, may
be intermittently bloodstained
Repeatedly bloodstained
Purulent, intermittently bloodstained
Copious, purulent and malodorous, may be
bloodstained.

Pneumococcal pneumonia Purulent, stained with rusty red blood

Taking a sputum sample
Preparation and equipment Pulmonary oedema Pink or white and frothy
»» The nurse should ensure the appropriate
equipment is available, including: Pulmonary embolus Bright red
–– Alcohol gel, depending on local policy.
Blood clotting abnormality Bright red
–– Sterile gloves.
–– A disposable apron. Trauma such as intubation, tracheostomy, or
–– Protective eyewear. Bloodstained
lung contusion, or following tracheal suction
–– Sterile 0.9% sodium cholride solution
for inhalation via a nebuliser if required. Mucoid (clear, grey or white, like raw egg
Chronic obstructive pulmonary disease
white)

Figure 1. Testing a sputum specimen for disease Infection or dehydration Thick, tenacious

Infection, allergy, secretions that have not

Purulent, yellow or green
been expectorated

Asthma Sputum plugs or stringy sputum

Presence of eosinophils
Green or yellow
(indicative of infection)

Pseudomonas infection Thick, green, musty smelling, sticky

Haemoptysis Contains blood — varying from slight streaks

(caused by the conditions listed above) to frank bleeding
(Adapted from Hough 2014)

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evidence & practice / clinical investigations series
load, caused by the accumulation of
bacteria overnight (Dougherty and Lister
2015) and secretions are most copious at
that time of day (Randle et al 2009).
Procedure
1. Decontaminate your hands to prevent
cross infection, either using alcohol gel
or soap and water, in accordance with
local policy.
2. Put on disposable gloves, an apron and
protective eyewear to prevent cross
infection.
3. Remove the cap of the sputum specimen
collection container and avoid touching
the inside of the container, to prevent
cross infection. The container used to
collect the specimen is not required to
be sterile, but must be clean and free
from organisms of a respiratory origin.
Material originating in the bronchi and
alveoli has to pass through the pharynx
and mouth. These areas have a normal
commensal population of bacteria, which
means that sputum is never free from
organisms (Dougherty and Lister 2015).
4. Ask the patient to clear the back of
their nose and throat. They may need to
gargle, spit and rinse to ensure the mouth
is free from debris (Welch 2017).
5. Encourage the patient to take at
least three deep breaths and force
out a deep cough. If the patient has
difficulty producing sputum, a specialist
respiratory physiotherapist can be
asked to assist in airway clearance
techniques. Otherwise, a deep cough
first thing in the morning may obtain
the required result. Alternatively, a
nebulised solution of 0.9% sodium
chloride can be administered to enable
expectoration.
6. Ask the patient to spit their secretions
into the sputum container. Ensure the
sample obtained is sputum, not saliva. At
least 15mL of sputum should be collected
if possible (Randle et al 2009).
7. Seal the sputum container securely to
prevent cross infection.
8. Remove and discard the gloves and
apron in the clinical waste bin and
decontaminate your hands to avoid
cross infection.
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9. Label the sputum sample and send
the specimen to the laboratory for
microbiology culture and sensitivity
tests or cytology immediately. The
bacterial population alters rapidly,
immediate dispatch and analysis are
necessary to ensure accurate results
(Dougherty and Lister 2015).
10. Document the episode of care. Record
the colour, amount and consistency of
the sputum collected.
Patient care
Explain the procedure to the patient and the
rationale for carrying it out. Vital signs and
nursing observations are not usually required
before, during or after this investigation,
unless the patient is extremely breathless
or distressed. Bloodstained sputum, known
as haemoptysis, can be frightening for the
patient, especially if a large volume of blood
has been expectorated. In this situation,
additional time and reassurance should be
given to the patient. When documenting
sputum production, record the colour,
amount and consistency of the sputum,
because this information provides indications
of improvement or deterioration in the
patient’s condition and the effectiveness of
treatment.
A patient who is having difficulty
expectorating sputum would benefit
from referral to a specialist respiratory
physiotherapist who can recommend
a wide variety of airway clearance
techniques, such as the active cycle of
breathing, autogenic drainage, postural
drainage or the forced expiration technique
(Bott et al 2009, Hough 2014).
Interfering factors
Haematemesis is the term used to describe
blood that has been vomited. It can be
confused with haemoptysis, but it is likely to
be combined with food rather than mucus
(Hough 2014). It is more acidic than sputum
and dark brown in colour, resembling coffee
grounds (Hough 2014). Distinguishing
between haematemesis and haemoptysis
requires taking a careful patient history to
identify whether expectorated blood has been
swallowed and vomited, or aspirated and
expectorated (Hough 2014).
nursingstandard.com
Potential complications 2015). Specimens are readily contaminated USEFUL RESOURCES
Suction may be required if the patient is by suboptimal technique; avoiding »» British Lung
not well enough to cough, or is sedated accidental contamination of the sample will Foundation
or intubated. This may require the use of help to avoid confusing or misleading results www.blf.org.uk
a nasopharyngeal airway and specialist (Dougherty and Lister 2015). »» British Thoracic
training to avoid injury to the patient. Society
Obtaining an insufficient sputum sample Conclusion www.brit-thoracic.
will make analysis and diagnosis difficult. Sputum analysis is an important clinical org.uk
The greater the quantity of material sent investigation. If it is performed correctly, it
for laboratory examination, the greater the can provide useful information for diagnosis
chance of isolating a causative organism and treatment of a variety of conditions.
(Dougherty and Lister 2015). Delaying Sputum can usually be obtained in a non-
transport of the sample to the laboratory invasive manner, with minimal distress to
can result in an inaccurate specimen. The the patient. It is important for the nurse to
bacterial population alters rapidly, so ensure a sufficient sputum sample is collected
immediate dispatch and analysis will ensure from the patient and that it is sent to the
accurate results (Dougherty and Lister laboratory for analysis immediately.

References

Bott J, Blumenthal S, Buxton M et al (2009)
Guidelines for the physiotherapy management
of the adult, medical, spontaneously breathing
patient. Thorax, 64, Suppl 1, i1-i51.
Dougherty L, Lister S (2015) Interpreting
diagnostic tests. In The Royal Marsden
Manual of Clinical Nursing Procedures. Ninth
edition. Wiley Blackwell, Chichester, 509-594.
Hough A (2014) Physiotherapy in Respiratory
and Cardiac Care: An Evidence-Based
Approach. Fourth edition. Cengage Learning,
Andover.
Marieb EN (2011) Essentials of Human University Press, Oxford, 285-362.
Anatomy and Physiology. Tenth edition.
Pearson Education, San Francisco CA. Welch (2017) Sputum Assessment. In Preston
W, Kelly C (Eds) Respiratory Nursing at a
Randle J, Coffey F, Bradbury M (Eds) (2009) Glance. Wiley Blackwell, Chichester, 36-37.
Respiratory system. In Oxford Handbook
of Clinical Skills in Adult Nursing. Oxford

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