Tes Lab Respiratory

Laboratory examination
1
for respiratory disorders
Ruland DN Pakasi
R.Pakasi - FK-UNDANA Kupang 21/05/2019

2 Introduction
Laboratory Diagnosis of the Disease

1. exam. of Sputum
2. exam. of pleural effusion
3. exam. of whole blood
4. exam. of microbiologiy
5. Blood Gas Analysis (BGA)
6. Radiology/Imaginga Studies

3
Introduction
Contents of Sputum
 Mucus (trachea, bronchi,

pharynx)
 Effusion (from pulmo)
 Saliva

4  Early morning or 24 hrs
Introduction  To be coughed
Specimen collection  Stimulation: aerosol or
hypertonic solution
 Container:
 Clean, wide-mouthed
 Tightly stoppered
 Size: adjusted
 Bottle, Petri dish, Cardboard
 Sterile

 Pour specimen into petri dish  thin
5 layer
Introduction  Place carbon paper under the petri dish
 Remove suspected materials to glass
Procedure of Examination slide
 The whole surface should be observed,
focus to the suspected abnormals
 Help to focus the details
 Let dry
 Staining (Gram, Wright,ZN)
 Cover glass
 Study the smear

6
Sputum Examination
 Total output 24 hrs.
Macroscopic Examination
 Large volume: >100 mL
 Pulmonary edema
 Bronchiectasis
 Pulmonary tuberculosis
 Lung abscess
 Pulmonary hemorrhage

7
Sputum Examination • Large volume: > 100 mL
Macroscopic Examination • Accumulation (pus or
 VOLUME
fluid( from extenal origin
(subphrenic abscess)
• Index of prognosis
• Increasing: progression
• Gradual decreasing:
healing
• Sudden decrease:
obstruction

8
Sputum Examination
• Mixing of mucus & pus
Macroscopic Examination • varies the color
 COLOR • Transparent to opaque
• Green to yellow pus: advanced TB
• Bright green: Icterus, pneumonia,
Lung infarction
• Bright red/patchy: early TB
• Rusty red: Lobar pneumonia
• Brown: Cardial decompensation

9
Sputum Examination •  serous, mucous, purulent
seropurulent  mucopurulent
 CONSISTENCY &
APPEARANCE • Lobar pneumonia
• rusty, sputum crudum
• Invert tube
• Early acute bronchitis & asthma
• Thicky mucus
• Pulmonary edema
• Serous + blood spot

10
Sputum Examination
 Stratification
• Bronchectasis
• Gangrene
• Abscess
Frosthy
More/less clear

11 • masses of minute, greyish fat
Sputum Examination
globules, fatty acid crystals, and
Macroscopic Examination bacteria
 DITTRICH PLUGS • seen in the bronchi in bronchitis

and bronchiectasis, in pulmonary
gangrene & fetid bronchitis
• Yellowish or grey body formed in
bronchi
• pin-head ~ bean size
• Sometimes expeactorated alone
• crushed  very putrid odor

12
Sputum Examination
Macroscopic Examination • Microscopic: granular debris,

 DITTRICH PLUGS fat globules, fatty acid crystals,
large clumps of bacteria
• Most common in
• Chronic bronchitis, bronchial
asthma,brochiectasis

13
Sputum Examination
Macroscopic • Yellowish white masses

Examination • Composed of central
 CURSCHMANNS’ thread, delicate fibrils
SPIRAL surround tightly or loosely
• Adhered WBC & Charcot-
Leyden suggestive of
bronchial asthma, acute
bronchitis & pulm.TB

14
Macroscopic
Examination • Composed of fibrin, white or
grayish; may be reddish brown
 BRONCHIAL CASTS (blood pigment)
• Size & appearance : vary
• Small threadslarge tree-
branching
• Fibrinous, hemorrhage or
mucous

15
• Size & appearance : vary
Macroscopic • Rolled into balls or tangled
Examination masses
 BRONCHIAL CASTS • Floating out in water over a
black background
• Frequently seen in
Fibrinous bronchitis
Pneumonia (consolidation)
Chronic cardiac disease
TB

• Small concretions of calcarous
16 material
Sputum Examination • Vary in size: fine sandlike particles
 large stones
Macroscopic • Formated due to necrosis of
Examination infected tissue and deposition of
calcium salts, may result from small
 PNEUMOLITH, Lung foreign bodies, bits of clothing,etc
stones
• Chronic TB
• In long period
• Lung stones encrusted
ulceration expectorate with
hemorrhage  active
inflammationparoxysmal
cough, wheezing & dyspnea
(stone asthma)

17
Sputum Examination • Small particles of caseous material
Macroscopic • Varying size: pinhead~bean
Examination • Consisting of:
 CHEESY MASSES • Fragments of necrotic tissue or bits
of cartilagealenous rings
• Color:
• Considerable pusyellow
• Decomposed blood/pigments 
dark

18
Macroscopic
Examination
• Commonly seen in
 CHEESY MASSES
 Pulmonary TB
 Pulmonary abscess
 Pumonary gangrene

19
• Particles of clothing, etc
Macroscopic
Examination • By gunshot or penetreting
FOREIGN BODY wound
• Other objects (peanut, buttons,
marbles, etc)
• Through mouth & inhale
(children

20 Sputum Examination
MIcroscopic Examination
• Unstained preparation
1. Curshmann’s spiral
2. Elastic fibers 4. Pigment cells
3. Crystals 5. Myelin globules
• Charcot-Leydens crystals 6. Fungi
• Fatty acid crystals
7. Animal parasites
• Cholesterol crystals
• Leucin & tyrosine crystals
• Inorganic salts crystals

• Stained preparation 1. Leukocytes
2. Eosinophils
3. Lymphocytes
4. Endothelial leukocytes
5. Erythrocytes
6. epithelium

 Structures accompanying those
Unstained preparation on Macroscopic description
1.Curshmann’s spiral
• Appear as slender, curled,
2.Elastic fibers highly refractive, branching
fibers of uniform 
• As a network or in bundles;
sometimes retain alveoli
arrangement (differ from
mold, cotton, or hairs)

Unstained preparation
• Derived from alveoli, bronchi or
blood vesselstheir presence
2.Elastic fibers indicate destruction of
pulmonary tissue
• Advanced TB
• Ulcerating
bronchiectasis]ulcerating
malignancy

Unstained preparation
3.Crystals • Charcot-Leydens crystals

• Fatty acid crystals
• Cholesterol crystals
• Leucin & tyrosine crystals
• Inorganic salts crystals

Unstained preparation • Colorless pointed
 3.Crystals Charcot- hexagones; may appear
Leyden quite needlelik; may be
purplish-red
• Soluble in water & acetic
acid
• Derived from eosinophil
desintegration, associated
with bronchial asthma
Microscopic Examination  Unstained preparation

3.Crystals: Charcot-Leyden
• Derived from alveoli, bronchi or
blood vesselstheir presence
indicate destruction of
pulmonary tissue
• Advanced TB
• Ulcerating bronchiectasis, ulcerating
malignancy

• Resemble long colorless
needles, straight or curved
27
Sputum Examination • Seen singly or in tuft
• Soluble in acids, hot alcohol
Microscopic Examination chloro form & alkali; not in
 3.Crystals Fatty acid water & acids (a way to
differentaite from elastic
fibers)
• Usually associated with
• Chronic pulmonary TB
• Gangrene
• Putrid bronchitis
• Bronchiectasis

28 • Colorless and transperrant
Sputum Examination thin rhmobic, rectangular or
Microscopic Examination
oblique plates with noched
edges
3.Crystals Cholesterol
• Siza: small or large
• Generally found in
• Chronic lung abscess
• Empyema
• Chronic TB
• Liver abscess (openinginto
bronchi)

29
• Decomposition of protein
 3.Crystals Leucin & • Leucine
Tyrosine
• Gray or yellowish spheres,
resembling fat cells, singly or
in clumps
• Sometimes: disc with
concentric arrangement
resembling the traverse cut
of a tree tunk

• Decomposition of protein
30 • Tyrosine
• Fine silky needles
• Appear singly, in groups or
 3.Crystals Leucin & arranged in single or double
Tyrosine tufts
• Moore readily detected if
sputum isa evaporated in the
air
• Both crystals my be found

• Rupture of empyema into the
lung
• Perforation of liver abscess

31
3.Crystals Inorganic salts
Little or no clinical significance

32 • Contains hemosiderin
Sputum Examination (long continued passive
congestion of the lung
resulting from poorly
4.Pigmented cells
compensated heart
Heart-failure cells disease)
• To identify
• 1 drop 10%
potassium
ferrocyyanide
• 1 drop 0.1n HCl
• Prussian blue color

33
 4.Pigmented cells • Cells are found in
o Chronic passive pulmonary
 Heart-failure cells congestion
o Cardic decompesation
o Pulonary infarction
o Pulm.post hemorrhage

34
• Similar to heart failure cell
Dust cells
• Contain black/brownish
black angular granules
• Seen in sputum of
anthracosis
• Less important

 Appear as uncolor objects
35
 Irregulaly shaped, oval, round
Sputum Examination or pear-shaped
 In groups of various sizes
Microscopic Examination  Highly refractile having a
5.Myelin globules greenish sheen
 Show spiral markings or
concentric rings
 May be seen in scanty
sputum in the morning of
healthy person
 Abundant in mucoid sputum
of bronchitis
 Little or no clinical
significance

36
Microscopic Examination • To identify

6.Fungi  10% KOHdissolve
cellular debris
 Apply coverglass and
heated over a slow flame
 Examine under 16-mm
and 4-mm microscope

37
Sputum Examination • Should be noted:
Microscopic Examination Larvae: Necator
7.Animal parasite americanus, Strongy loides,
Ascaris
Ova: Paragonimus,
Endamoeba hysto lytica
(tropozoit & cyst)
Flagelete protozoa
Echinococcus cyst

38
 Sputum Examination
 Limfosit
 Dominan pada tbc ringan
 Leukocyte
Microscopic  Hampir selalu ada,
Examination menunjukkan kontaminasi
 Banyak : perdarahan atau
eksudasi
 Pneumonia, kavitas tbc,
penyakit kronis ulseratif

 1.Albumin
39  Jumlah sedikit pd asma &
 Sputum Examination bronkitis kronik
Chemical Examination  1-3 g/L : pada Pneumonia &
TBC
 2.Lemak
No clinical significance
 3.Darah
Darah-samar (Occult
blood)
Benzidine test

 Sputum
Characteristics in ◦ Awal penyakit
Various Diseases ◦ Dahak sedikit, mukoid, lengket
Asma Bronkial ◦ Mengandung sedikit WBC & epitel, serng ada
garis-darah
◦ Kemudian
◦ Dahak banyak, mukopurulent,
kekuningan/kelabu
◦ Mengandung epitel, bakteri, sel nanah
21/05/2019 R.PAKASI - FK-UNDANA KUPANG 40

 Sputum
Characteristics in Dahak sedikit, putih-keabuan
Various Diseases
Semi-transparan
Bronkitis Akut
Kental & lengket
Isi: eosinofil, kristal Charco-Leyden, spiral
Curschmman

 Sputum
Characteristics in Awal penyakit
Various Diseases  Dahak banyak, muoid
Bronkitis Fibrinosa  Mengandung WBC, epitel, bekuan fibrin (torak
bronkial)
 Bisa ada darah dan mucus

 Sputum
Characteristics in
Various Diseases Dahak purulent, banyak
Sering bau tengik
5.Bronkiektasis
Warna kelabu
Ada stratifikasi jika dibiarkan
Bisa ada darah bila hemoragi/ kerusakan jaringan

Sputum
Characteristics in  Dahak banyak, kuning atau hijau
Various Diseases  Bau bervariasi: agak manis sp tengik menusuk
Abses Paru  Ruptur: nanah spt krim dlm jumlah banyak,
mengandung fragmen jar.paru
 Sel nanah banyak; bisa ada benang elastik dan
RBC

Sputum
Characteristics in Dahak banyak, cair, warna hijau~coklat
Various Diseases bau busuk
Gangren paru Ada stratifikasi bila dibiarkan
Mengandung jaringan nekrotik, benang elastik
Nanah & epitel tidak banyak
Bakteria: bacili & spirocheta

Sputum
Characteristics in
Various Diseases Dahak biasanya rusty, sangat lengket
Pneumonia Lobaris Warna orange~hijau

Sel nanah, epitel dan pneumokokus predominasi
Biasa ada torak fibrinous

Sputum
Characteristics in
Various Diseases Dahak tak begitu banyak, mukopurulent
Bronkopneumonia
Mengandung sel nanah, RBC, bakteri
Sputum sangat tidak spesifik

Sputum Awal
Characteristics in ◦ Dahak sedikit, mukoid
Various Diseases ◦ Bisa mengandung partikel kuning opak
TBC Paru Lanjut
◦ Dahak sangat banyak
◦ Kavitas: partikel keju
◦ Darah bisa ada/ tidak
◦ BTA: bisa pada awal/ lanjut

Sputum
Characteristics in
Various Diseases Dahak sangat banyak (1-2 L), serous-eksudatif,
encer, berbusa
Udem Paru
Warna pink~coklat gelap
Mengandung massa hialin, RBC (variasi jumlah),
WBC & epitel (sedikit)

Sputum
Characteristics in Dahak sedikit, lengket,mukoid
Various Diseases Mukus campur darah
Infark Paru Sel alveoler berpigment & RBC bisa ada
Infeksi sekunder
◦ Purulent, banyak WBC & bakteria
◦ Bau tengik

 Examination of pleural
51
fluid
Ruland D.N.Pakasi

52  Examination of Pleural Effusion
Specimen Collectng
• Thoracentesis
• Indications
• Undiagnosed pleural effusion
• Therapeutic: massive symptomatic
effusion
• EDTA tubes  total & Differential
cell count
• Heparinized tubes
• Aerbic & anaerobic bacterial
culture blood agar
Classification of Pleural Effusion

TRANSUDATE EXUDATE
hydrostatic pressure or  capillary permeability or 
plasma oncotic pressure lymphatic resorption
• Congestive Heart Failure 1.Infections
• Hepatic cirrhosis • Bacterial pneumonia, Tuber
• Hypoproteinemia culosis,
(e.g.nephrotic syndrome)
• other granulomatous
disease (sarcoidosis,
histoplamosis, etc). Viral or
mycoplasma pneu monia
Classification of Pleural Effusion

TRANSUDATE EXUDATE
hydrostatic pressure or  capillary permeability or 
plasma oncotic pressure lymphatic resorption
2.Neoplasms
• Bronchogenic carcinoma,
Me tastatic carcinoma,
Lympho ma, Mesothelioma,
Pulmo nary infarct
3. Noninfectious
inflammatory disease
involving pleura
R.Pakasi - FK-UNDANA Kupang 4. Rheumatoid disease, SLE 21/05/2019
Criteria for Pleural Exudates
Pleural effusion/serum protein ratio  0.50
Pleural effusion/serum LD ratio  0.60
Pleural effusion LD  2/3 upper limit

of normal serum LD
Pleural effusion cholesterol > 45 mg/dL

Pleural effusion/serum cholesterol  0.30
Serum-pleural fluid albumin gradient < 1.2 g/dL
Pleural effusion/serum bilirubin ratio  0.60
56
Examination of Pleural
Fluid
Microscopic  WBC count

Examination  <1000 cells/L: Transudates
 > 1000 cells/L: Exudates
 RBC count
 >100.000/L: suggestive of malignancy, trauma,
pulmonaru infarction
 Diff.Leucocyte Count & Cytology
 Cytocentrifugation, air-dried, and Romanowsky’s
staining
 For malignancies esp.hematologic

57
Examination of Pleural Fluid
 Diff.Leucocyte Count &

Microscopic
Cytology
Examination
 Mesothelial cells:
 inflammatory processes
 Scarce in TBC pleuritis,
empyema, rheumatoid pleuritis

58

Microscopic
Examination  Diff.Leucocyte Count &
Cytology
 Well-differentiated
carcinoma
 Highly undifferentiated
 Panel of immuno
chemical stain for
confirmation

59
Microscopic  Neutrophils: (>50%)

Examination  Predominate in pleural
inflammations
 Lymphocytes (>50%)
 Predominate in TBC, viral
infection, malignancy,
Rheumatoid pleuritis, SLE
 Eosinophils (>10%)
 Pnumothorax, trauma,
R.Pakasi - FK-UNDANA Kupang
Pulmonary infarction, CHF. 21/05/2019
etc
60 Examination of Pleural Fluid
• Protein/ Albumin
• Little value of
Dif.Diagnosis
Chemical • Glucose
Examination •  Serum level
• Low: < 60 mg/dL
• Low: Pl.eff/serum ratio <
0.5
Malignancy, Tuberculosis,
Nonpurulent bacterial infections,
Lupus pleuritis 21/05/2019
• Lactate
• Significantly  in
bacterial and
Chemical tuberculous pleural
Examination infections
• Moderate  in
malignant effusions

• Enzymes
• Amylase
•  Indicates pancreatitis,
esophageal rupture, or
malignant effusions
• Lactate Dehydrogenase
• Level rise in proportion to
Chemical the degree of inflammtion
Examination • Declining level means
inflammatory process is
resolving
• Increasing levelworsening
condition equiring
aggressive
workup/treatment
63
• Enzymes
• Adenosine deaminase
(ADA)
• Rich in T
Chemical
Lymphocytessignifica
Examination
ntly  in tbc pleuritis
• Interferon-gamma (IFN-)
• Significantly  in tbc
pleuritis

• Lipids
• Effusion appear to be
chylous/ milky due to the
Chemical presence of lecithin-
globulin complex
Examination • Require lipoprotein
electrophoresis to confirm
chylothorax

• C-Reactive Protein (CRP)

• 90 mg/L in
parapneumonic infections
• 26 mg/L in tuberculous
effusion
Chemical
• 23 mg/L in malignancy
Examinatio effusin
n • Clinical useful
• Index of disease acitivity
• Measure of response to
therapy

• Rheumatoid Factor (RF)

• RF titer of  1:320 is
reasonable evidence of
Immunologic rheumatic pleuritis.
Studies • RF titer up to 1: 1280
identified in 41% patients
with malignant effusion,

• Antinuclear Antibody
(ANA)
Immunologic • Not clinically useful
Studies • Elevated titers also occur
in various conditions

68 BTK
69
Respiratory Diseases
Clinical and Laboratory Studies

70 Bacterial Pneumonia
 Routine Laboratory Tests  may not be useful for diagnostic

purposes but are useful for classifying
illness severity and site-of-
care/admission decisions
 Serum chemistry panel (sodium,
potassium, bicarbonate, blood urea
nitrogen [BUN], creatinine, glucose)
 Arterial blood gas (ABG) determination
(serum pH, arterial oxygen saturation,
arterial oxygen pressure) – Hypoxia
and respiratory acidosis may be
present.
 Venous blood gas determination
(central venous oxygen saturation)

 Routine Laboratory  may not be useful for diagnostic

Tests purposes but are useful for classifying
illness severity and site-of-
care/admission decisions
 Complete blood cell (CBC) count with
differential
 Serum free cortisol value
 Serum lactate level

 Blood studies  CBC count with differential

 Leukocytosis & a left shift
 may be observed in any bacterial
infection; however, its absence,
particularly in patients who are elderly,
should not cause the clinician to
discount the possibility of a bacterial
infection
 Coagulation studies
  international normalized ratio
(INR) = severe illness. This finding
may herald the development of
disseminated intravascular
coagulation.

 Sputum evaluation  Gram stain and culture should be

performed before initiating antibiotic
therapy
 The WBC count should be > 25 per
low-power field.
 upper airway samples and
 Transtracheal
cultures obtained initially on
Aspiration
admission
 Fiberoptic bronchoscopy has
largely replaced transtracheal
aspiration for obtaining lower
respiratory secretions

74 Laryngotracheo bronchitis (Croup)
• Leucocytosis
Blood
• Granulocytosis
Nasopharyngeal • Usually show H.influenzae

culture type B
• Positive for H.infle]uenzae

Blood culture
(50% cases)

75 Pertussis (Whooping Cough)
• Leucocytosis (<100.000/L with

Blood marked lymphocytosis (<90%)
• Granulocytosis
• Fluorescent antibody staining

Nasopharyngeal
provides a rapid and specific
smear
diagnosis
Blood culture • Negative result

76 Viral Pneumonia
• WBC normal/decreased with relative

lymphocytosis
Blood • WBC > 15.000/L2ndary bacteral
infection
• Complement-fixing antibodies:
Immuunologic antibody titer against specific
causative virus 4x rise
Blood culture • Negative result

77 Fungal Pneumonia
Blood
• Proteinuria
Urine
• WBC and Casts
• Culture
Sputum
• Gram stain
Blood culture • Frequently positive

78 Lung abscess
• A complete white blood cell count with differential

Blood leukocytosis & a left shift.
Proteinuria • WBC and Casts
• Culture & Sensitivity tests

Sputum
• Gram stain
• Frequently positive
Blood culture • If tuberculosis is suspected, acid-fast
bacilli stain and mycobacterial culture is
requested 21/05/2019
79

80

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Laboratory examination

R.Pakasi - FK-UNDANA Kupang 21/05/2019

Laboratory Diagnosis of the Disease

R.Pakasi - FK-UNDANA Kupang 21/05/2019

 Mucus (trachea, bronchi,

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 DITTRICH PLUGS • seen in the bronchi in bronchitis

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Macroscopic Examination • Microscopic: granular debris,

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Macroscopic • Yellowish white masses

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3.Crystals • Charcot-Leydens crystals

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Microscopic Examination  Unstained preparation

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• Both crystals my be found

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Little or no clinical significance

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Microscopic Examination • To identify

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Pneumonia Lobaris Warna orange~hijau

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