Induced Sputum Guidelines for Practice

Transcription

1 Induced Sputum Guidelines for Practice Full Title of Guideline: Induced Sputum Guidelines for Practice Author (include and role): Division & Speciality: Version: 3 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Greg Stretton, Senior Physiotherapist Greg.stretton@nuh.nhs.uk Clinical Support, Physiotherapy Senior Physiotherapists at NUH Trust wide physiotherapists September, 2021 This guideline applies to patients who have difficulty expectorating pulmonary secretions, and were a sputum sample may assist in diagnosis. It applies to patients with conditions that have led to immunosuppression e.g. HIV and bone marrow transplantation and were a less invasive procedure to gain a sputum sample is indicated/preferable. Review of research, minor changes to wording, grammar and spelling errors corrected. Meta analysis of randomised controlled trials. Expert Summary of evidence base this committee reports or opinions and / or clinical experiences of guideline has been created from: respected authorities. Recommended best practise based on the clinical experience of the guideline developer This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Page 1 of 8

2 Induced Sputum Guidelines for Practice 2018 Version: This replaces the Induced Sputum Guidelines for Practice, May 2015 Review Date: October 2021 Contact: Greg Stretton, Senior Physiotherapist Specialty Medicine Cancer Services and Eleanor Douglas, Lecturer/Practitioner Physiotherapist Ext: / Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments / feedback. Please note this guideline is for sputum induction in adults only. Indications for Use This protocol describes the procedure for gaining induced sputum samples from nonexpectorating patients, to assist in the diagnosis of pneumocystic carini pneumonia (PCP), fungal and viral infections. Sputum induction has been demonstrated to be a sensitive and costeffective technique in the diagnosis of PCP, it is a method that saves time and is less invasive than a bronchoscopy and Bronchi Alveolar Lavage (BAL) (Cruciani et al 2002). An induced sputum can also be a useful tool in diagnosing pulmonary TB (Scheicher et al, 2003; McWilliams et al, 2002). Precautions Asthma the induced sputum procedure can cause bronchospasm so known asthmatics should be monitored throughout for signs of intolerance. Patients with a reduced FEV1 see above. High percentage oxygen support (>40%) the induced sputum procedure requires the ultrasonic nebulizer which does not have a high flow-rate. Therefore it cannot be used in conjunction with oxygen via a T-piece. If a patient requires oxygen they must be on either nasal cannula or nasal optiflow. Tuberculosis any patient suspected of having TB should have induced sputum carried out in a negative pressure room, where the air content can be ventilated out. These factors need to be weighed up against the clinical need for a sputum sample. Contraindications Pulmonary Embolism Cardiovascular instability Pneumothorax Fractured ribs / chest trauma Bronchospasm Patient is independently expectorating Patient has eaten within 4 hours Page 2 of 8

3 Complications Nausea/Vomiting limited if the patient has been made nil by mouth for 4-6 hours. Bronchospasm If the patient shows any sign of bronchodpasm (reduced SpO2; increased work of breathing; audible wheeze on auscultation) Oxygen Desaturation SpO2 monitoring throughout is recommended. Equipment List 1. One metal trolley 2. NaCl (7%) 7 x 4ml hypertonic saline - 28mls prescribed 3. 2 x Salbutamol 2.5mg prescribed (1 pre-investigation, 1 PRN). 4. Ultrasonic Nebuliser 5. Normal nebuliser compressor and attachments 6. Disposable cup and lid for ultrasonic nebuliser 7. Large bottle of sterile water 8. Elephant tubing 9. Oxygen filter 10. Scissors 11. Face mask with holes covered 12. Nasal cannula if the patient requires additional oxygen throughout the procedure 13. Oxygen supply 14. Six sputum pots labeled and numbered 15. Sick bowl 16. FFP3 face-mask for the member of staff performing the procedure Please note the use of 7% NaCl can be negotiated with the requesting consultant. There is no acknowledged ideal concentration of NaCl for an induced sputum, varying from 3-10% (Bell et al, 2004). NUH uses 7% as a standard because it is readily available from pharmacy and has caused less cancellations. Previously NUH has used lower NaCl solutions, requested from pharmacy, but this often led to the procedure being cancelled due to the unavailability of the Nacl solution. Procedure - Preparation Action Ensure a referral has been made by a doctor (SHO or above) and has been documented in the medical notes. The procedure has been explained to the patient and consent has been given. Rationale Induced sputum requests must be through a medical referral. Minimizes distress and informs the patient of the procedure. Confirms the patient is willing to undertake the procedure. The patient must be nil-by-mouth To prevent the patient from vomiting and contaminating for 4 hours prior to the procedure. the sputum samples. It is recommended that the procedure is completed first thing in the morning and the patient is NBM from midnight. Check that 28mls of 7% hypertonic Hypertonic saline is routinely available in 4ml vials at 7%. Page 3 of 8

4 saline has been prescribed and collected from pharmacy. The procedure should be performed in a negative pressure room if at all possible, especially if TB is suspected. If another dosage has been requested by the medical team, it may take longer to arrive from pharmacy. If there is any uncertainty about the expected infecting agent full protection must be taken. For further details contact Infection Contro.l Procedure Pre-Nebulisation Obtain consent from the patient on the morning of the investigation. Sit the patient upright in a chair or on their bed. The patient should be given 2.5mg Salbutamol prior to the induced sputum if cardiovascular status allows. NB. If the patient is under a Haematologist, please check with the haematology doctor that they are in agreement with this. Ensure a PRN Salbutamol 2.5mg nebuliser has been prescribed and it setup so that it can be used quickly in an emergency. Gloves, apron and a, FFP3 facialmask should be worn by the physiotherapist during the procedure. Auscultate the patient s chest. Set up the ultrasonic nebuliser using sterile water in the chamber, the amount of which is indicated on the side of the chamber. Place a disposable cup in the top of the ultrasonic nebuliser and fill with 28mls of hypertonic saline. The saline should be double checked with 2 qualified members of staff to confirm expiry date, correct dosage and concentration prior to administration Place the filter on the ultrasonic between the base and the shorter piece of tubing. Place the lid on the cup and use 2 sections of elephant tubing to connect the cup to the nebuliser (this will fit on top of the filter). A second length of elephant tubing (approximately 12 sections Confirms the patient is still willing to undertake the procedure. Provides a good position for the patient when they are coughing. This significantly reduces the likelihood of bronchospasm (Pizzichini et al, 2002). Haematology doctors may not be happy with the cardiovascular risk out-weighing the bronchospasm benefit of pre-nebulisation. Salbutamol must be available incase the procedure induces bronchospasm (Leigh et al 1994 and Castagaro et al 1999). This reduces the amount of nebulised saline inhaled by the therapist and protects them from any harmful airborne particles expectorated by the patient. To ensure no bronchospasm is present. To avoid contamination. To avoid contamination and ensure saline administered is of correct dosage and concentration and that it has not expired This reduces the likelihood of external infectious agents being passed into the patient. This will allow the nebulised saline to be picked up by the through-flow of the nebuliser. This carries the nebulised saline to the patient. Page 4 of 8

5 long) attaches to the other outlet on the cup lid and to the face mask. Use a mouth-piece or a face mask with the side holes taped up. The patient may wish to wear spectacles or a dressing over the top of the mask. To provide maximum nebulisation of the hypertonic saline. Spectacles / dressing reduces the amount of saline that is blow into the eye region and improves patient comfort and compliance. Procedure During Nebulisation Monitor the patient s oxygen saturations during the procedure and provide supplementary oxygen via nasal cannula if saturations drop below patient s normal range. After the 1 st minute, auscultate the patient to assess whether there is any bronchospasm present. This should also be done, regardless of time, if the patients sounds wheezy or reports tightness. If the patient appears in respiratory distress, ie. Increased work of breathing, bronchospasm and reduced SpO2, stop the hypetonic saline and give the PRN Salbutamol via 6-10l of O2, to bring the SpO2 back into a normal range. Allow the patient to inhale the nebuliser for minutes, or until it has all been inhaled, temporarily stopping it when the patient expectorates (Scheicher et al, 2003). If a cough is not elicited gentle vibrations or percussion over the patients chest can be carried out in sitting or side lying unless patient has any contraindicating factors e.g. rib Fractures The first specimen (1) is discarded. The next 4 samples are collected in sterile sputum jars. These jars should be numbered 2-5. If less than 4 samples are Desaturation during the procedure may occur (Leigh et al 1994; Castagnaro et al 1999) Bronchospasm can occur at any time and can present very quickly. All patients should be monitored throughout the procedure. If any signs of bronchospasm present, stop the investigation and immediately commence the second Salbutamol neb. If bronchospasm occurs, the patient may require higher amounts of Oxygen to remain within their normal SpO2 range. To illicit a spontaneous cough. To try to mobilise secretions in order to gain the sputum specimens. This sputum is from more proximal airways. These can then be labeled and sent for M,C & S (2), virology (3), fungal (4) and PCP (5). The M C & S is used to identify more common Page 5 of 8

6 obtained, disregard M,C & S. If 6 samples are obtained, disregard 1 and 2 and send the latter 4. Always send the last sample expectorated for PCP. There may be other tests that the medical team require such as Acid-fast Bacilli (AFB, for TB), Actinomycosis & Nocardia. The test is stopped if: o The patient has expectorated 6 times. o The patient vomits. o The patient goes into bronchospasm. o SpO2 drops below acceptable limits. o The patient does not wish to continue. infections. For patients that are appropriate for an induced sputum it is more likely that Viral, Fungal and PCP infections are what is being investigated. This will be the deepest most distal airway sample. This test may be requested by the medical team to identify / rule out a particular infection. This is to ensure the patient is willing to continue, it is clinically indicated and it is safe to do so. Procedure Post Nebulisation Send the samples immediately to microbiology. Document the outcome of the procedure in the medical notes. When the procedure is finished disregard the elephant tubing, disposable cup. Lid and mask/mouthpiece in a yellow clinical waste bin. Clean the chamber and surfaces of the ultrasonic nebuliser with hard surface wipes, as outlined in the cleaning protocol A second induced sputum is contraindicated for 48 hours. To allow analysis to be made as soon as possible. To ensure communication with the medical team and to cover yourself from a legal position. To ensure the disposable equipment is disposed of appropriately as clinical waste. To avoid cross infection (Paggiaro et al, 2002). References Bell D, Leckie V, McKendrick M. Use of the induced sputum procedure in the investigation of smear-negative pulmonary turberculosis. Oxford Journals: Clinical Infectious Diseases 38 (10) p Castagno A, Chetta A, Foresi A, D Ippolito R, Malorgio R et al. Effect of sputum induction on spirometric measurements and arterial oxygen saturation in asthmatic patients, smokers and healthy subjects. Chest (4); Cruciani M, Marcati P, Malena M, Bosco O, Serpelloni G and Mengoli C. Meta analysis of diagnostic procedures for pneumocystis carinii pneumonia in HIV infected patients. European Respiratory Journal ; Page 6 of 8

7 Leigh TR, Kirby K, Gazzard BG and Collins JV. Effects of sputum induction on arterial oxygen saturation and spirometry in HIV infected patients. European Respiratory Journal (3): McWilliams T, Wells AU, Harrison AC, Lindstrom S, Cameron RJ, Foskin E. Induced Sputum and bronchoscopy in the diagnosis of pulmonary tuberculosis. Thorax 2002; 57(12): Olivieri D, D Ipolito R and Chetta A. Induced sputum: diagnostic value in interstitial lung disease. Current Opinion in Pulmonary Medicine (5); Paggiaro PL, Chanez P, Holz O, Ind PW, Djukanovic R, Maestrelli P and Sterk PJ. Sputum induction. European Respiratory Journal : Supple. 37: 3 8. Pizzichini E, Leigh R, Djukanovic R and Sterk PJ. Safety of induced sputum. European Respiratory Journal : Supple. 37: Pryor JA and Prasad AS. Physiotherapy for Respiratory and Cardiac Problems Third Edition. Churchill Livingstone. Chapter 6 Marcos Eduardo Scheicher ME, Filho JT, Vianna EO Sputum induction: review of literature and proposal for a protocol. Sao Paulo Med Journal 2003; 121(5): Page 7 of 8

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