Sputum Induction

Policy

Category: Control of Infectious Diseases
Subject: Sputum Induction
Division: Health Protection
Policy Number: CA.82.01.210
Effective Date: May 18, 2016

POLICY STATEMENT

Wellington-Dufferin-Guelph Public Health (WDGPH) will provide comprehensive tuberculosis (TB) clinical services, including sputum induction to clients in the community who may have active TB. Sputum induction will be done by physician order and when the clinic is staffed with a Control of Infectious Diseases (CID) Public Health Nurse (PHN) in conjunction with the respirologist or the Medical Officer of Health. Sputum induction will be done using administrative, environmental, and personal protection controls to minimize risk to staff, physicians, and WDGPH clients. This sputum induction procedure will normally be done during a TB clinic, but may be done outside of TB clinic if conditions of procedure are observed.

SCOPE

This policy applies to all WDGPH CID staff that assist in the sputum induction procedure.

DEFINITIONS

TB clinic – A clinic operating regularly at the Guelph WDGPH office for the assessment and management of persons with possible, suspect, or confirmed active or latent tuberculosis disease.

Respirologist – A physician who has attained a Fellowship of the Royal College of Physicians and Surgeons of Canada in Respirology.

Sputum Induction – A procedure used for clients who have trouble producing sputum spontaneously and is used as an aid in the diagnosis of pulmonary TB.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure: CA.82.02.210 Sputum Induction
Health Protection and Promotion Act, 1990
Ontario Public Health Standards, 2008
Canadian Tuberculosis Standards (as current, online edition)
Tuberculosis Prevention and Control Protocol (MOHLTC, as current)
Guidance for Tuberculosis Prevention and Control Programs in Canada (Pan-Canada Public Health Network, 2011)

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases

APPROVED BY

Director, Health Protection 


Procedure

Category: Control of Infectious Diseases
Subject: Sputum Induction
Division: Health Protection
Procedure Number: CA.82.02.210
Effective Date: May 18, 2016

PROCEDURE

Sputum induction is a procedure used for clients who have trouble producing sputum spontaneously. The client inhales nebulized 3% hypertonic saline solution which results in the liquefaction of mucous membrane secretions and expectoration of same. Sputum induction is considered simple and non-invasive and when successful, precludes the need for a more invasive procedure.

Indications:

Sputum induction may be useful for a variety of medical conditions; however, when conducted at the Wellington-Dufferin-Guelph Public Health (WDGPH) unit, this procedure will only be undertaken as an aid in the diagnosis of pulmonary tuberculosis (TB).

Contraindications and Precautions:

1. 3% hypertonic saline can cause bronchoconstriction and the induction must only be performed under medical supervision (medical specialist/physician present in clinic area).

2. Sputum induction may cause severe coughing and consideration of alternative procedures should be considered in persons with the following conditions:

  • Haemoptysis of unknown origin
  • Acute respiratory distress  (e.g., bronchospasm)
  • Unstable cardiovascular status
  • Hypoxia
  • Pneumothorax
  • Severe chest pain
  • Fractured ribs or other chest trauma
  • Recent eye surgery

3. Persons who lack the capacity to follow instructions.

4. The physician who obtains consent is indicating that the client is an acceptable candidate for this procedure

Infection Control:

1. Sputum induction is to only be conducted in the clinic room dedicated to sputum induction (with booth), which is located within the designated/tested negative pressure area at the Chancellors Way office.

2. Staff must wear full personal protective equipment (PPE) during the sputum induction, adequate for both airborne and droplet precautions. PPE will include N95 respirator, face shield or safety goggles, gown, and gloves.

3. The door of the clinic room must be kept closed during the procedure and for a minimum of one hour after the end of the procedure. The door must be posted with a sign indicating the room cannot be entered and provide the appropriate time when room use can resume.

Consent form:

Once the client has received information from the physician and from the TB clinic staff about the induced sputum procedure, the client is required to read, ask any additional questions, acknowledge understanding, and sign the Consent to Induced Sputum Procedure form (HPDTB(F)17) prior to commencing the procedure. The client must be attended at all times during the procedure by a minimum of one public health nurse (PHN) or physician. The physician must remain in the TB clinic area at all times to be accessible during the procedure.

Procedure:

1. Prior to commencing the procedure, ensure the sputum induction booth and air compressor have been cleaned and are operational.

2. Prior to commencing the procedure, ensure that the TB clinic respirologist or MOH is on-site in the clinic area and is aware that a sputum induction is scheduled. The ordering physician will administer, complete, and sign the pre-induction section of the Sputum Induction Assessment (HPDTB(F)17) prior to commencing procedure.

3. Prior to commencing the procedure, ensure a new mask or mouthpiece and tubing is attached to the nebulizer as per the manufacturer’s instructions. Place the pulse oximeter on client’s finger and ensure it remains in place during the entire procedure.

4. Fill the nebulizer cup with one nebule (4 ml) of 3% NaCl to the appropriate fill line, as per the manufacturer’s instructions. Ensure the selector dial on the nebulizer top is turned to the continuous mode and NOT the intermittent mode position. Don appropriate personal protective equipment (PPE), including fit-tested N95 mask, goggles or face shield, disposable gown, and gloves. An emergency fob must be taken into the clinic room during the procedure.

5. Affix Do Not Enter: Procedure in Progress sign to the clinic room door .If entering during an emergency please wear N95 mask.

6. Reinforce the procedure and possible side effects to the client (including, but not limited to, coughing, dry mouth, and excess salivation). Discuss they will likely feel a tickling effect in their throat and they should not try to suppress the cough. Advise they should notify the attending PHN or physician if assistance is needed at any time during the procedure.

Note: Client should not be left alone at any time during the procedure. If PHN requires assistance use the emergency fob to call another staff member to room.

7. Instruct the client that they are to breathe only through their mouth. Give client a nose clip to assist with this. Instruct the client to place the mouthpiece in mouth and inhale and exhale normally keeping their mouth firmly sealed over the mouthpiece. Ensure the client does not cover the exhalation valve on the bottom of the mouthpiece.  If the client is unable to use the mouthpiece a mask can be used in place of the mouthpiece.  Select the large or small mask and attach firmly to the nebulizer. Saliva should be expectorated into a disposable kidney basin. Expectorated sputum should be coughed up and captured in a sterile container.

8. Turn the machine on and position the client comfortably in the induction booth. Indicate that the client should remain in the booth, facing forward, for the duration of the procedure.

9. Allow the client to inhale the hypertonic NaCl for five minutes. The client should then be instructed to take several deep breaths. If this does not induce spontaneous coughing, encourage the client to attempt to force a cough.

10. The client must be observed closely during the entire procedure for signs of discomfort and/or respiratory distress.

11. Immediately stop the procedure if the client shows any signs of distress, or complains of feeling unwell, light-headed, uncomfortable or oximetry indicates O2 saturation is declining.

12. If the client is unable to produce a sputum specimen after 15 minutes of inhalation, stop the procedure.

13. Assess the client’s condition post-procedure. If there are any concerns regarding the client’s condition, immediately ask for a physician assessment and contact the CID Manager/Supervisor. 

14. The ordering physician will administer, complete and sign the post sputum induction section of the Sputum Induction Assessment form (HPDTB(F)17) including the discharge order for the client.

15. The ordering physician will ensure client is in stable condition prior to issuing discharge order. The client must remain in the room until coughing has stopped and client’s breathing and vital signs have returned to pre-assessment level.

16. If the client requires a mask before leaving the room, ensure that a supply of surgical masks is available and worn appropriately prior to the client leaving.

17. Remove the nebulizer chamber and tubing from the machine and discard. Wipe down the induction booth and non-disposable equipment (air compressor, pulse oximeter, BP cuff, stethoscope) with an appropriate tuberculocidal disinfectant. Discard the plug type filter from the air compressor and replace with a new one for next use.

18. Package and process the specimen(s) for submission to the Public Health Ontario Laboratory.

19. Document the procedure and how it was tolerated in the client’s chart/record.

RESPONSIBILITIES

Management will:
  • Require that CID PHNs read and understand the policy and procedure in order to ensure the procedure is performed in a safe manner
Employees will:
  • Follow the procedure for sputum induction and ask questions of the Manager/Supervisor if they are unsure of any part of the procedure

DEFINITIONS

Negative Pressure Area – An area with a ventilation system that generates negative pressure to allow air to flow into the area but not escape from the area, as air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air from escaping the room.

Sputum – A mixture of saliva and mucous coughed up from the respiratory tract.

Saliva – A watery substance located in the mouth, secreted by the salivary gland.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy CA.82.01.210 Sputum Induction
CA.56.01/02.114 Safety Pendants
CA.50.01/02.101 Documentation Practices
Health Protection and Promotion Act, 1990
Ontario Public Health Standards, 2008
Canadian Tuberculosis Standards (as current, online edition)
Canadian Immunization Guide (as current, online edition)
Tuberculosis Prevention and Control Protocol (MOHLTC, as current)
Guidance for Tuberculosis Prevention and Control Programs in Canada (Pan-Canada Public Health Network, 2011)
Nursing Practice Guideline: Consent (College of Nurses of Ontario, 2009)
Nursing Practice Standard: Documentation (College of Nurses of Ontario, 2008)
Manufacturer’s Instructions: AeroEclipse XL; Reusable Breath Actuated Nebulizer
Manufacturer’s Instructions: OMBRA Table Top Compressor
Manufacturer’s Instructions: ComfortSeal* Mask (with Elbow Adapter)

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases

APPROVED BY

Director, Health Protection