如何正确留置呼吸道标本
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– e.g. white paper, a white pot, or a white sink surface
• The more intense the yellow color, the more likely it is a bacterial infection (e.g. bronchitis, bronchopneumonia, or pneumonia)
To determine the quality of lower respiratory specimens by the specimens’ appearance 判断下呼吸道标本的质量
Good quality 质量好
• Blood-stained 染血 • Muco-purulent 粘液脓性 • Purulent 化脓性
Rank no. 1 the most common culture 痰培养排第一名
Specimen is easy to collect (before starting antibiotic is difficult) 标本容易收集（但使用抗生素前标本是困难）
Simple, non-invasive 简单,非侵入性 Easy to perform in laboratory 简单容易在实验室处理 Must grow some bacteria 一定可以培养出细菌 Most of the time is to culture rubbish 大部分是培养垃圾 Laboratory diagnosis is passive 实验室诊断是被动
2
What are the specimens?什么标本？ How to do?怎么做？ How to report ?如何报告？ All specimens MUST be processed in a
microbiological safety cabinet 所有标本必须在安全柜处理
– Sputum (Most common)痰液(最常见)
• Collected by deep cough深咳收集
– Tracheal aspirate 气管吸出物
• Collected via the endotracheal tube 通过气管插管收集
– Bronchial aspirate 支气管吸出物
5
Lower Respiratory Tract (LRT) Specimen下呼吸道标本 (2)
More Invasive specimen collection具侵入性的标本采集 –Broncho-alveolar lavage (BAL)支氣管肺泡灌洗
• Collected by washing a segment of lung with sterile saline using a flexible bronchoscope 收集使用支气管镜洗涤肺的无菌 生理盐水
Specimen is not representative of lower respiratory secretions, specimen should be rejected and repeated 标本不代表下呼吸道分泌物，标本应予以拒绝及重采
10
Macroscopic Examination用眼检验
Presence of squamous epithelial cells, Absence of PMNs and mixed bacterial flora including Gram positive cocci in pairs, chains and clusters and gram negative cocci and rods 鳞状上皮细胞, 缺乏白细胞,混合菌群
Other bacterial culture 细菌培养
Macroscopic examination 眼检验
Microscopic examination – Gram stain
革兰氏染色镜检
Culture identification and
sensitivity test 鉴定及药敏
Culture Identification and
• Pink sputum 粉红色痰 – Sputum evenly mixed with blood from alveoli and/or small peripheral bronchi. 痰均匀地从肺泡和/或小支气管末梢 血液混合 – Massive blood 大量的血液 – Cavitary tuberculosis or tumor such as lung cancer, or lung abscess; bronchiectasis; lung infarction; pulmonary embolism.肺结核或肿瘤如肺癌，或肺脓肿;支气管扩张; 肺梗死;肺栓塞
Blood-streaked sputum血丝痰 inflammation of throat (larynx and/or trachea) or bronchi; lung cancer; other bleeding erosions, ulcers, or tumors of the lower airway. 喉（喉和/或气管）或支气管发炎;肺癌;其它出血,溃疡,或下气道的肿瘤
Respiratory Specimen Culture: To Perform or Not To Perform?
呼吸道标本培养:做还是不做？
Sputum Culture in Mainland 痰培养在内地
Respiratory disease/problem is common 呼吸道疾病为最常见
• To determine the quality of lower respiratory specimens by the amount of squamous epithelial cells (SECs) and polymorphonuclear leukocytes (PMNs) per low power field (LPF)低倍镜检鳞状上皮细胞和白细胞量确定下呼吸道标本的质量
Presence of Large amount of squamous epithelial cells 大量鳞状上皮细胞
13
Dissection of a purulent sputum 浓痰解剖
阳 性 菌
Can stick to the wall 可以粘在墙上
阴 性 菌
Schematic Diagram to show uneven distribution of bacteria 显示细菌分布不均的示意图
• 更深的黄色，越有可能是细菌感染（例如支气 管炎，支气管肺炎，肺炎）
May imply therapeutic consequences such as prescription of antibiotics
抗生素处方或許需要
8
Sputum Colour 痰液颜色 (2)
Bloody (hemoptysis) 血（咯血）
sensitivity test 鉴定及药敏
Sputum Colour 痰液颜色 (1)
• Any hint of yellow color suggests an airway infection • 黄色提示呼吸道感染 • Does not indicate between the types of organisms causing disease • 但不表示各类致病 • Best detected when viewed on a very white background • 最佳在一个非常白色背景上观察
Specimens 标本
Mycobacteria tuberculosis (TB) culture 结核分枝杆菌（TB）培养
Macroscopic examination 眼检验
Microscopic examination - Ziehl-Neelsen (ZN) / Auramine O (AO) Stain
Presence of PMNs , presence of predominant organism – Gram positive diplococci which are Streptococcus pneumoniae
有白细胞,主要有 - 革兰氏阳性双球菌
12
Sputum Gram staining from poor quawk.baidu.comity specimens质量较差的标本
9
Microscopic Examination镜检
- Gram Stain in Bacteriology Lab
• A simple and rapid diagnostic tool for presumptive identification of pathogens 简单而快速的诊断工具
Note: criteria in different laboratories may vary不同实验室可以改变
SECs per LPF 鳞状表皮细胞
<25
<25
>25
PMNs per LPF 白细胞
>25
<25
>25
>25
<25
Action 行动
Culture培養
Culture培養
Oropharyngeal contamination is suggested; culture have to be interpreted with cautions, only pathogens with predominant growth are reported over normal flora建议为口咽污染,培養必须谨慎诠释，只报道主要病原菌群
–Protected specimens brushings (PSB) 保護毛刷標本
• Collected by aspiration of material from airways by a protected brush catheter in the bronchoscope 支气管镜保护毛刷导管
http://www.microbelibrary.org/library/laboratory-test/2873-sputumunacceptable-specimens-and-staining-artifacts
3
呼吸道解剖
4
Lower Respiratory Tract (LRT) Specimen下呼吸道标本 (1)
–Endotracheal tip (ET tip)支氣管插管尖 –Endotracheal tube (ET tube)支氣管插管
6
Workflow of Microbiological Investigation of Lower Respiratory Specimens (PWH)
呼吸道标本工作流程 (PWH)
• Collected by direct aspiration of material from the large airways of respiratory tract using a flexible bronchoscope 纤维支气管镜 由肺气道直接抽吸收集
UK Standards for Microbiology Investigations -Investigation of bronchoalveolar lavage, sputum and associated specimens. The Standards Unit, Public Health, England. 2015; 3.1.
Suggestion of oro-pharyngeal contamination
X 建议为口咽污染 • Salivary 唾液 • Muco-salivary 粘性唾液 • Mucoid 粘液
11
Sputum Gram staining from good quality specimens
质量好的标本
• The more intense the yellow color, the more likely it is a bacterial infection (e.g. bronchitis, bronchopneumonia, or pneumonia)
To determine the quality of lower respiratory specimens by the specimens’ appearance 判断下呼吸道标本的质量
Good quality 质量好
• Blood-stained 染血 • Muco-purulent 粘液脓性 • Purulent 化脓性
Rank no. 1 the most common culture 痰培养排第一名
Specimen is easy to collect (before starting antibiotic is difficult) 标本容易收集（但使用抗生素前标本是困难）
Simple, non-invasive 简单,非侵入性 Easy to perform in laboratory 简单容易在实验室处理 Must grow some bacteria 一定可以培养出细菌 Most of the time is to culture rubbish 大部分是培养垃圾 Laboratory diagnosis is passive 实验室诊断是被动
2
What are the specimens?什么标本？ How to do?怎么做？ How to report ?如何报告？ All specimens MUST be processed in a
microbiological safety cabinet 所有标本必须在安全柜处理
– Sputum (Most common)痰液(最常见)
• Collected by deep cough深咳收集
– Tracheal aspirate 气管吸出物
• Collected via the endotracheal tube 通过气管插管收集
– Bronchial aspirate 支气管吸出物
5
Lower Respiratory Tract (LRT) Specimen下呼吸道标本 (2)
More Invasive specimen collection具侵入性的标本采集 –Broncho-alveolar lavage (BAL)支氣管肺泡灌洗
• Collected by washing a segment of lung with sterile saline using a flexible bronchoscope 收集使用支气管镜洗涤肺的无菌 生理盐水
Specimen is not representative of lower respiratory secretions, specimen should be rejected and repeated 标本不代表下呼吸道分泌物，标本应予以拒绝及重采
10
Macroscopic Examination用眼检验
Presence of squamous epithelial cells, Absence of PMNs and mixed bacterial flora including Gram positive cocci in pairs, chains and clusters and gram negative cocci and rods 鳞状上皮细胞, 缺乏白细胞,混合菌群
Other bacterial culture 细菌培养
Macroscopic examination 眼检验
Microscopic examination – Gram stain
革兰氏染色镜检
Culture identification and
sensitivity test 鉴定及药敏
Culture Identification and
• Pink sputum 粉红色痰 – Sputum evenly mixed with blood from alveoli and/or small peripheral bronchi. 痰均匀地从肺泡和/或小支气管末梢 血液混合 – Massive blood 大量的血液 – Cavitary tuberculosis or tumor such as lung cancer, or lung abscess; bronchiectasis; lung infarction; pulmonary embolism.肺结核或肿瘤如肺癌，或肺脓肿;支气管扩张; 肺梗死;肺栓塞
Blood-streaked sputum血丝痰 inflammation of throat (larynx and/or trachea) or bronchi; lung cancer; other bleeding erosions, ulcers, or tumors of the lower airway. 喉（喉和/或气管）或支气管发炎;肺癌;其它出血,溃疡,或下气道的肿瘤
Respiratory Specimen Culture: To Perform or Not To Perform?
呼吸道标本培养:做还是不做？
Sputum Culture in Mainland 痰培养在内地
Respiratory disease/problem is common 呼吸道疾病为最常见
• To determine the quality of lower respiratory specimens by the amount of squamous epithelial cells (SECs) and polymorphonuclear leukocytes (PMNs) per low power field (LPF)低倍镜检鳞状上皮细胞和白细胞量确定下呼吸道标本的质量
Presence of Large amount of squamous epithelial cells 大量鳞状上皮细胞
13
Dissection of a purulent sputum 浓痰解剖
阳 性 菌
Can stick to the wall 可以粘在墙上
阴 性 菌
Schematic Diagram to show uneven distribution of bacteria 显示细菌分布不均的示意图
• 更深的黄色，越有可能是细菌感染（例如支气 管炎，支气管肺炎，肺炎）
May imply therapeutic consequences such as prescription of antibiotics
抗生素处方或許需要
8
Sputum Colour 痰液颜色 (2)
Bloody (hemoptysis) 血（咯血）
sensitivity test 鉴定及药敏
Sputum Colour 痰液颜色 (1)
• Any hint of yellow color suggests an airway infection • 黄色提示呼吸道感染 • Does not indicate between the types of organisms causing disease • 但不表示各类致病 • Best detected when viewed on a very white background • 最佳在一个非常白色背景上观察
Specimens 标本
Mycobacteria tuberculosis (TB) culture 结核分枝杆菌（TB）培养
Macroscopic examination 眼检验
Microscopic examination - Ziehl-Neelsen (ZN) / Auramine O (AO) Stain
Presence of PMNs , presence of predominant organism – Gram positive diplococci which are Streptococcus pneumoniae
有白细胞,主要有 - 革兰氏阳性双球菌
12
Sputum Gram staining from poor quawk.baidu.comity specimens质量较差的标本
9
Microscopic Examination镜检
- Gram Stain in Bacteriology Lab
• A simple and rapid diagnostic tool for presumptive identification of pathogens 简单而快速的诊断工具
Note: criteria in different laboratories may vary不同实验室可以改变
SECs per LPF 鳞状表皮细胞
<25
<25
>25
PMNs per LPF 白细胞
>25
<25
>25
>25
<25
Action 行动
Culture培養
Culture培養
Oropharyngeal contamination is suggested; culture have to be interpreted with cautions, only pathogens with predominant growth are reported over normal flora建议为口咽污染,培養必须谨慎诠释，只报道主要病原菌群
–Protected specimens brushings (PSB) 保護毛刷標本
• Collected by aspiration of material from airways by a protected brush catheter in the bronchoscope 支气管镜保护毛刷导管
http://www.microbelibrary.org/library/laboratory-test/2873-sputumunacceptable-specimens-and-staining-artifacts
3
呼吸道解剖
4
Lower Respiratory Tract (LRT) Specimen下呼吸道标本 (1)
–Endotracheal tip (ET tip)支氣管插管尖 –Endotracheal tube (ET tube)支氣管插管
6
Workflow of Microbiological Investigation of Lower Respiratory Specimens (PWH)
呼吸道标本工作流程 (PWH)
• Collected by direct aspiration of material from the large airways of respiratory tract using a flexible bronchoscope 纤维支气管镜 由肺气道直接抽吸收集
UK Standards for Microbiology Investigations -Investigation of bronchoalveolar lavage, sputum and associated specimens. The Standards Unit, Public Health, England. 2015; 3.1.
Suggestion of oro-pharyngeal contamination
X 建议为口咽污染 • Salivary 唾液 • Muco-salivary 粘性唾液 • Mucoid 粘液
11
Sputum Gram staining from good quality specimens
质量好的标本