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Diagnostic value of sputum induction in respiratory disorders dr anirban dutta
- 1. DIAGNOSTIC VALUE OF SPUTUMINDUCTION Dr. Anirban Dutta 2nd year PG
- 2. “Things don’t happen.They are made to happen”- JOHN F. KENNEDY
- 3. Introduction Non invasivetool in diagnosing ◦ Occupational asthma ◦ COPD ◦ Lung cancer ◦ ILDS ◦ TB ◦ Opportunistic infections
- 4. Advantages : Non invasive Simple Safe Economical Easilyavailable Acceptable to most of the patients Repeatable and Reproducible Serve in monitoring of course and therapy
- 5. Methods Sputum inductionis done with ◦ Normal saline ◦ Hypertonic saline ◦ Uridine Triphosphate Using a Ultrasonic Nebulizer with a output of 1ml/min. Prerequisites ◦ Written informed consent ◦ Using baseline FEV1 or PEFR ◦ Pretreatment with 200-400gm of salbutamol inhalation prior to induction
- 6. Use ofBeta 2 agonists for sputum induction is also documented FEV1,PEFR fall>20% - STOP Procedure
- 7. SAMPLE PROCESSING Processedwithin 2hrs Can be stored at -20°C or -40°C in dimethyl sulfoxide solution . Fluid phase mediators can be estimated even to <18hrs of sputum induction Total cell count is done before centrifugation using a hemocytometer. Cell viability is determined by a triptan blue exclusion method
- 9. Differential countby Wright’s or Giemsa stain for Eosinophils, Neutrophils,macrophages, lymphocytes and bronchial epithelial cells Toluidine blue - mast cells and basophils. Results have better contrast when staining time is increased from 10 mins to 60 minutes Immunocytochemical staining further
- 10. Results differfrom Selected sputum and Unselected Sputum It also differs from the use of ◦ Dithiothreitol ◦ Delayed processing of the sputum ◦ Effect of temperature ◦ Dilution ◦ Filtration and centrifugation Standardization is very important for uniformity of results
- 11. Bronchial Asthma Discrepanciesand lack of correlation with histological changes and various investigations such as Bronchoscopic findings ,FEV1/PEFR repeat Biopsies and airways Hyperresponsiveness have given place to SPUTUM INDUCTION to evaluate and assess airway inflammation. Elevated Eosinophilic count of 3% provides a clue for the asthma in 80% & 50% of patients with or without inhaled corticosteriods respectively.
- 12. Thus eosinophiliccount can help in ◦ evaluation of therapeutic measures i.e persistence of eosinophils shows either non compliance or acute exacerbation ◦ Requiring to either increase the dose of inhalation of corticosteroids ◦ Addition of another anti inflammatory drug Neutrophilia warrants an attack by viral infection In children , sputum eosinophilia also well correlates with bronchial hyper- Responsiveness and severity ◦ Sputum induction is safer in ChildHood
- 13. Chronic Obstructive Pulmonary Disease Neutrophilic inflammation plays a major role in inferring presence of infection in COPD Activation of neutrophil signifies Clinical Improvement Occurrence of eosinophilia in induced sputum in patients of COPD indicates requirement of Inhalational steroids ◦ Thus can be used as predictor of response to steroid therapy.
- 14. Pulmonary Tuberculosis Preferredmethod over gastric lavage in Children Useful in dry coughers and smear negative cases It can be used for infants and children from HIV prevalent areas Smear + for AFB increases by 29% with sputum induction and results are better with 1st day. It increases case detection rate of smear – ve Pulmonary TB as well as smear +ve pulm. TB
- 15. Pneumocystis Carini Pneumonia Sputuminduction is ◦ sensitive ◦ Specific ◦ Low cost ◦ Well tolerated method in immunocompromised patient to diagnose pneumnocystis carinii pneumonia (PCP) in HIV positive patients
- 16. LUNG CANCER Cytologicaldiagnostic yield by sputum induction in the central growth as well as lung in the elderly is almost 74% The diagnostic technique utilized include ◦ Specific oncogene activation ◦ Tumor supressor cell deletion ◦ Genomic instabilty ◦ Abnormal methylation
- 17. Community Acquired Pneumonia Nebulizationtechnique using Hypertonic saline is preferred in children as recommended by PNEUMONIA ETILOGY RESEARCH FOR CHILD HEALTH (PERCH)in children hospitalized with severe pneumonia provided no C/I exists
- 18. Cystic Fibrosis Tofind infection and inflammation is more useful in cases with less sputum production This procedure is more preferable over BAL Advantages : ◦ 2 fold increase in sputum production ◦ Escalated indices of inflammation TLC , absolute neutrophil count , interleukin levels & neutrophil elastase activity ◦ A large number of non squamous cells and higher detection rate of pathogens & colony counts to diagnose CF as compared to
- 19. Sputum Induction : FUTUROLOGY It should be routinely suggested for Nonproductive cough In sarcoidosis also it is of CHOICE – diagnostic method of BAL with fiberoptic bronchoscope are well correlated with CD4: CD8 ratio and levels of tumor necrosis factor in induced sputum both in pre and post treatment.
- 20. Cellular characteristicsand presence of mineralogenical particles in induced sputum can also offer help in diagnosis and assesment of patients with mineral dust exposure and extrinsic alveolitis In obtaining diagnostic yields of ◦ lipid laden macrophages in GERD ◦ Hemosiderin laden macrophages in Left ventricular failure Sputum induction can offer high diagnostic yield in pleural TB when there is no evidence of parenchymal pulmonary disease
- 21. Conclusion Requires standardization,trained technicians and back up support of laboratory analysis of microbiological , biochemical and Histopathological Evaluation New window in diagnosing and assesing various lung disaeases and disorders Neverthless it requires a proposal for protocol for future directions. We also need to identify the reason for underuse of this technique
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