Sputum in case of pneumonia

Macroscopic examination of sputum

Macroscopic examination of sputum in patients with pneumonia has an important diagnostic value, often helping to establish the nature of the pathological process and possible complications (eg, bleeding or suppuration).

The amount of sputum for respiratory diseases can vary within wide limits (from 10 to 500 ml and more per day) and is determined mainly by two factors:

1. character and degree of activity of the pathological process in the lungs and
2. the possibility of unchecked coughing up of sputum.

A relatively small amount of sputum (not more than 50-100 ml per day) is typical for most patients pneumonia and other inflammatory lung diseases (acute tracheitis, acute and chronic bronchitis and other).

A significant increase in the amount of sputum (more than 150-200 ml per day), as a rule, is observed in diseases accompanied by education the cavity communicating with the bronchus (lung abscess, tuberculous cavern, bronchiectasis), or tissue decay (gangrene, disintegrating lung cancer and other). It should be noted in this connection that sometimes in these patients the amount of sputum may decrease due to a violation of drainage of the inflammatory focus.

In severe patients with pneumonia and patients of senile age, cough reflex suppression is often observed, and therefore sputum is secreted in small amounts or absent altogether.

The color of sputum depends on the composition of the pathological tracheobronchial secretion and the presence of various impurities (for example, blood impurities).

The main causes of sputum color change in pneumonia and other lung diseases

Color and nature of sputum	The nature of the pathological process
Colorless, transparent (mucous sputum)	Many acute diseases of the lungs, trachea and bronchi (especially in the initial stage), accompanied mainly by catarrhal inflammation. Often - chronic diseases in remission
Yellowish shade (mucopurulent)	The presence of a moderate amount of pus in the sputum. It is typical for the majority of acute and chronic lung diseases at a certain stage of the development of inflammation
Greenish shade (mucopurulent or purulent)	Stagnation of purulent sputum, accompanied by the disintegration of neutrophilic leukocytes and the release of enzyme verdoperoxidase, the transformation of the iron-porphyrin group of which causes a greenish tinge phlegm
Yellow (canary) color of phlegm	The presence in the sputum of a large number of eosinophils (eg, with eosinophilic pneumonia)
Rusty Color	The penetration of erythrocytes into the lumen of the alveoli by diapedesis and the release of hematin from the decaying erythrocytes (most characteristic of croupous pneumonia)
Pinkish color of serous sputum	Admixture of small red blood cells in serous sputum with alveolar edema of the lung
Other shades of red (scarlet, brown, etc.)	Signs of more significant blood impurities (hemoptysis, pulmonary hemorrhage)
Blackish or grayish color	Impurities of coal dust in sputum

It should be borne in mind that the appearance of impurities in the sputum, regardless of the nature of the underlying pathological process (catarrhal, purulent or fibrinous inflammation, swelling, etc.), significantly changes the color of phlegm (cm. below).

Smell of phlegm. Sputum is usually serous and mucous in nature has no smell. The offensive putrefactive smell of freshly isolated sputum indicates:

1. about putrefactive decay of lung tissue with abscessing of the lung, gangrene of the lung, disintegrating lung cancer;
2. on the decomposition of sputum proteins (including blood proteins) with prolonged exposure to it in cavities (abscess of the lung, less often - bronchiectasis), mainly under the influence of anaerobic flora.

The nature of phlegm. Depending on the consistency, color, transparency, odor and other physical signs revealed by macroscopic examination, four main types of sputum are distinguished:

1. Mucous sputum is colorless, viscous, odorless. It occurs in the initial stages of inflammation or when its activity subsides.
2. Serous sputum is also colorless, liquid, foamy, odorless. It appears, as a rule, with alveolar edema of the lung, when as a result of increasing pressure in the system of the small circle of blood circulation or the increase in the permeability of the vascular wall during inflammation increases the transudation into the lumen of the respiratory bunches of blood plasma rich in protein. Due to active respiratory movements (suffocation, shortness of breath), the plasma foams and is released in the form of a foamy liquid, sometimes diffusely colored pink, indicating a significant increase in the permeability of the vascular wall and bleeding by type per diapidesum.
3. Muco-purulent sputum - viscous, yellowish or greenish in color - is common in many diseases of the respiratory system, including pneumonia. In some cases, mucopurulent sputum may have a mildly expressed unpleasant odor.
4. Purulent sputum is a liquid or semi-liquid consistency, greenish or yellowish in color, often with an unpleasant odor. It occurs in acute or chronic suppuration in the lungs and bronchi, with the disintegration of lung tissue (abscess and gangrene of the lung, bronchiectasis, decaying lung cancer, etc.). When settling purulent sputum, two or three layers are usually formed. Purulent sputum in certain diseases of the lung (abscess, gangrene of the lung, bronchiectasis, purulent bronchitis) on standing for several hours is divided into two or three layers.

Two-layer sputum is more common with a lung abscess. The upper layer consists of a serous frothy liquid, and the lower layer consists of a greenish-yellow opaque pus.

Three-layer sputum is most typical for gangrene of the lung, although sometimes it can appear in patients with bronchiectasis and even putrefactive bronchitis. The top layer of such sputum consists of a foamy, colorless mucus containing a large number of air bubbles, from a turbid mucus-serous liquid of a yellowish-greenish color, the lower one - from a yellow or greenish opaque pus.

Hemoplegia. The admixture of blood in the sputum has a very important diagnostic value, often indicating the development of serious complications. Depending on the extent and nature of damage to the lung tissue and respiratory tract, an admixture of blood in the sputum (hemoptysis - haematoptoe) may be different: 1) blood veins, 2) blood clots, 3) rusty sputum, 4) diffusely colored pink sputum and m. If at a coughing the pure scarlet blood without an admixture of mucus or pus stands out, speak about occurrence of a pulmonary hemorrhage (haematomesis). Hemoptysis (haematoptoe) is the excretion of phlegm with blood. With pulmonary hemorrhage (haematomesis) during the cough, the patient is allocated pure scarlet blood (tuberculosis, lung cancer, bronchiectasis, traumatic injuries, etc.).

In pneumonia, especially with croupous pneumonia, it is also possible to give blood with phlegm in the form of "rusty" sputum, veins or blood clots. Hemoptysis and pulmonary hemorrhage can occur in other respiratory diseases. It should nevertheless be borne in mind that in actual clinical practice the impurity of blood in sputum can often have other characteristics. For example, contrary to popular belief, "rusty" sputum can occur not only in croupous pneumonia (typical cases), but also when focal and influenza pneumonia, with pulmonary tuberculosis with curdled decay, stagnation in the lung, edema of the lung, and the like. On the other hand, with croup pneumonia, sputum or blood clots may appear in the sputum, or, conversely, it does not have blood impurities and is mucosal or mucopurulent.

The main causes of hemoptysis and the most typical type of sputum

Main reasons	Character of blood admixture
Bronchoectasis, chronic purulent bronchitis	More often in the form of veins or blood clots in sputum purulent or muco-purulent
Croupous pneumonia	Rusty sputum
Abscess, gangrene of the lung	Purulent-bloody, semi-liquid, spiky-like consistency abundant sputum brown or red with a sharp putrefactive odor
Lung cancer	Bloody, sometimes jelly-like sputum (such as "crimson jelly")
Tuberculosis of the lung	Blood veins or clots in mucus-purulent sputum; when forming a cavity, a plentiful bloody sputum may appear in brown or red
Lung infarction	Blood clots or sputum, diffusely colored in brown
Alveolar edema of the lung	Diffusively colored pink frothy serous sputum
Staphylococcal or viral focal pneumonia	Blood veins or clots in mucus-purulent sputum, and "rusty" sputum
Actinomycosis of the lung	Blood veins or clots in mucopurulent or purulent sputum

It should be remembered that almost all of the diseases listed in the table can develop massive pulmonary hemorrhage.

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What is a cough for pneumonia?

Pneumonia is a disease, which is sometimes not easy to recognize. Often patients are concerned about coughing with pneumonia.

What can be caused by a cough?

Coughing is a reflex reaction of the body, which arises in response to the irritating effect of any factors. As irritants are dust, foreign bodies, sputum. Therefore, cough should not be considered an independent disease, it is just a symptom of a disease, including pneumonia.

Many agree that coughing is one of the most unpleasant symptoms. Firstly, it is often accompanied by painful sensations. Secondly, it prevents a person from leading a habitual way of life: a long protracted cough literally exhausts, especially it is felt at night. Thirdly, it causes psychological discomfort. Many people are familiar with the situation when a sudden attack of loud cough in a public place attracts the attention of others. In this situation, a person feels uncomfortable. Therefore, those who suffer from cough, are ready to buy any medicine, just to get rid of this symptom.

As for the inflammation of the lungs, it rarely flows without a cough. To suspect a person of this ailment, it is important to know what cough is with pneumonia. Usually it is at first dry, obtrusive and constant, often very strong. When the inflammation develops, the cough becomes wet, with the release of phlegm containing mucus, pus, blood veins. It is called productive. Although it is unpleasant, but much more favorable than dry, because it allows you to remove the sputum accumulated during illness from the respiratory tract. Together with the phlegm, all unnecessary is also removed, which accumulated there. It speeds up recovery. In addition, if the sputum is excreted well, this reduces the risk of complications. Therefore, it is not necessary to suppress such a reflex reaction. If the body itself does not cope with the task, then the drugs prescribed by the doctor come to the aid. They dilute sputum and promote its better separation.

As for the dry cough, it is a rather painful and unpleasant symptom. Since sputum is not excreted in this case, relief does not come. Attacks of dry cough are repeated many times, irritate the respiratory tract even more and cause new, more severe attacks. It turns out a vicious circle. Therefore, such a cough should be controlled.As a rule, after a few days it becomes wet.But, if during this time attacks of dry coughing cause a person discomfort, you should appoint him effective bronchodilators such as pectusin, licorice root syrups and Dr. Mom, Bromhexine, Mukaltin. To treat dry paroxysmal cough with pneumonia it is possible and folk remedies: a radish with honey or infusion of nettle.

Although moist cough with pneumonia is productive and contributes to the production of sputum, it must also be treated. First, sputum can be very viscous, especially in children, and it must be diluted. Secondly, if the sputum for a long time will be in the lungs, then it can develop bacteria. To stimulate the process of excretion of sputum, the patient is prescribed expectorants.

Another feature that is characteristic of pneumonia is this: usually a cough after pneumonia does not immediately pass.

It can be observed for a long period. And in adults, cough after pneumonia persists much longer than in children.

This is due to the final clearance of the lungs from phlegm. You need to perform breathing exercises, do chest massage, inflate and blow off the ball, do not swallow phlegm, which clears throat. So, the body will soon recover from the disease.

If the cough remains and does not pass for a long period, you should consult a doctor.

In such cases, usually not medicinal products are prescribed, but physiotherapy and folk remedies. To treat a cough after a disease, you need to take vitamin C, walk on fresh air, do gymnastics for the lungs, drink plenty of warm water, eat vegetables and fruits to strengthen immunity. Any catarrhal disease after a previous pneumonia can lead to a relapse. It is advisable after the inflammation of the lungs not to be supercooled and not overheat, to keep the temperature balance, to lead a healthy lifestyle and more often to be in the open air.

How dangerous is the sputum discharge with blood in pneumonia?

Sometimes with pneumonia, sputum has a rusty hue, which indicates the presence of blood in it.

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How dangerous is this for a person? It all depends on what pathogenic microorganisms caused by the disease. For example, for lobar pneumonia, sputum with blood is not dangerous, it is only a stage of the disease. But for focal pneumonia, the presence of blood in the sputum is a dangerous symptom. In any case, this manifestation of the disease should be alarming, additional diagnostics will be required.

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Sputum examination

Sputum is a pathological secret of the respiratory tract, which is secreted by cough and formed when damage to the mucous membrane of the trachea, bronchi and lung tissue by infectious, physical or chemical agents.

Sputum analysis in patients with pneumonia in many cases (although not always) allows:

• determine the nature of the pathological process;
• to clarify the etiology of inflammation of the respiratory tract and lung tissue, in particular to isolate the pathogen of inflammation;
• determine the main properties of the pathogen, including its sensitivity to antibiotics;
• evaluate the effectiveness of treatment.

Sputum analysis includes:

1. Macroscopic examination (determination of sputum character, its quantity, color, transparency, odor, consistency, presence of impurities and various inclusions).
2. Microscopic examination (determination of cellular and other sputum elements, as well as the study of microbial flora in native and stained smears).
3. Microbiological study (identification and study of the properties of the alleged causative agent of the disease).

The chemical study of sputum has not yet found wide application in clinical practice, although it also has some diagnostic significance.

Sputum for research

Sputum for examination is collected in the morning on an empty stomach after preliminary thorough rinsing of the mouth and throat with boiled water. Sometimes it is recommended that you rinse your mouth with a 1% solution of aluminum alum.

The patient coughs up sputum directly into clean, dry glassware with a tight-fitting lid. If microbiological examination of the sputum is expected, it is cleared into a sterile Petri dish or other sterile container. It is important to warn the patient that when sputum is collected, the ingestion of saliva into samples sent to the laboratory can significantly change the results of the study. Only freshly sputum is sent to the laboratory, since prolonged standing, especially at room temperature, leads to autolysis of cell elements and reproduction of microflora. If necessary, short-term storage of phlegm in the refrigerator is allowed.

Who to contact?

Laboratory assistant Pulmonologist

General properties of sputum

Number of sputum

The amount of sputum usually ranges from 10 to 100 ml per day. Few sputum is separated in acute bronchitis, pneumonia, congestion in the lungs, at the onset of an attack of bronchial asthma. At the end of an attack of bronchial asthma, the amount of sputum is increased. A large amount of sputum (sometimes up to, L) may be released during pulmonary edema, as well as in case of suppuration in the lungs, cavities with bronchus (with abscess, bronchoectatic disease, gangrene of the lung, with tuberculosis in the lung, accompanied by decay tissue). It should be borne in mind that a decrease in the amount of sputum released during suppuration in the lungs can be a consequence of stihaniya inflammatory process, and the result of a violation of drainage of the purulent cavity, which is often accompanied by deterioration patient. An increase in the amount of sputum may be regarded as a sign of worsening of the patient's condition if it depends on an exacerbation, for example, of a suppurating process; in other cases, when an increase in sputum is associated with improved drainage of the cavity, it is regarded as positive symptom.

Sputum color

Most sputum is colorless, the attachment of a purulent component gives it a greenish tinge that is observed with an abscess of the lung, gangrene of the lung, bronchiectasis, actinomycosis of the lung. When sputum appears in fresh sputum, sputum is colored in various shades of red (sputum hemoptysis in patients with tuberculosis, actinomycosis, lung cancer, lung abscess, with lung infarction, cardiac asthma and edema of the lungs).

Sputum of rusty color (with croupous, focal and influenza pneumonia, with pulmonary tuberculosis with curdled decay, stagnation in the lungs, pulmonary edema, with pulmonary form of anthrax) or sputum brown (in case of a lung infarction) indicates the content of not fresh blood in it, but the products of its decay (hematin).

Dirty-green or yellow-green color can have sputum, which separates with various pathological processes in the lungs, combined with the presence of jaundice in patients.

Yellow-canary color of sputum is sometimes observed with eosinophilic pneumonia. The ophthalmic sputum discharge is possible with lung siderosis.

Blackish or grayish sputum occurs with coal dust and smokers.

Sputum may be stained with some medications, for example, rifampicin stains the discharge into red.

Smell of phlegm

Sputum is usually odorless. The appearance of odor contributes to a violation of outflow of sputum. Putrid odor it acquires in the abscess, gangrene of the lung, with putrefactive bronchitis in result of joining putrefactive infection, bronchiectasis, lung cancer, complicated necrosis. For the revealed echinococcal cyst is characterized by a peculiar fruity smell of phlegm.

Sputum of sputum

Purulent sputum on standing is usually divided into 2 layers, putrefactive - on 3 layers (upper frothy, medium serous, lower purulent). Especially characteristic is the appearance of a three-layer sputum for gangrene of the lung, while the appearance of double-layered sputum is usually observed in the abscess of lung and bronchiectasis.

Sputum reaction

Sputum usually has an alkaline or neutral reaction. The decomposed sputum gets an acid reaction.

Nature of sputum

• Mucous sputum is excreted in acute and chronic bronchitis, asthmatic bronchitis, tracheitis.
• Muco-purulent sputum is characteristic for abscess and gangrene of the lung, silicosis, purulent bronchitis, exacerbation of chronic bronchitis, staphylococcal pneumonia.
• Purulent-mucous sputum is characteristic for bronchopneumonia.
• Purulent sputum is possible with bronchiectasis, staphylococcal pneumonia, abscess, gangrene, actinomycosis of the lungs.
• Serous sputum is separated with pulmonary edema.
• Serous-purulent sputum is possible with an abscess of the lung.
• Bloody sputum is excreted in case of lung infarction, neoplasms, pneumonia (sometimes), trauma of the lungs, actinomycosis and syphilis.

It should be noted that hemoptysis and impurity of blood to sputum are not observed in all cases of lung infarcts (in 12-52%). Therefore, the absence of hemoptysis does not give grounds for refusing the diagnosis of a lung infarct. It should also be remembered that it is not always possible to analyze sputum with the appearance of a large amount of blood in the lungs due to pulmonary pathology. To simulate pulmonary bleeding can, for example, gastric or nasal bleeding.

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Microscopic analysis of sputum

Microscopic examination of native and fixed stained sputum specimens allows detailed study of its cellular composition, and the known degree reflecting the nature of the pathological process in the lungs and bronchi, its activity, to reveal various fibrous and crystalline education, also having an important diagnostic value, and, finally, tentatively assess the state of the microbial flora of the respiratory tract (bacterioscopy).

At a microscopy use native and painted preparations of a sputum. To study the microbial flora (bacterioscopy), sputum smears are usually stained by Romanovsky-Giemsa, according to Gram, and for the detection of Mycobacterium tuberculosis, but Cilu-Nielsen.

Cellular elements and elastic fibers

Of the cellular elements that can be detected in the sputum of patients with pneumonia, epithelial cells, alveolar macrophages, leukocytes and erythrocytes are of diagnostic importance.

Epithelial cells. Flat epithelium from the oral cavity, nasopharynx, vocal folds and epiglottis has no diagnostic value, although the detection of a large number cells of a flat epithelium, as a rule, testifies to a low quality of a sputum specimen delivered to a laboratory and containing a significant admixture saliva.

In patients with pneumonia, sputum is considered suitable for investigation if, with a microscopy with a small increase, the number of epithelial cells does not exceed 10 in the field of vision. A larger number of epithelial cells indicates an unacceptable predominance of oropharyngeal contents in the biological sample.

Alveolar macrophages, which in small amounts can also be found in any sputum, are large cells of reticulohistiocyte origin with an eccentrically located large nucleus and abundant inclusions in the cytoplasm. These inclusions can consist of macrophage-absorbed tiny dust particles (dust cells), leukocytes, and the like. amount alveolar macrophages is increased in inflammatory processes in the pulmonary parenchyma and respiratory tract, including pneumonia.

Cells of cylindrical ciliated epithelium lining the mucous membrane of the larynx, trachea and bronchi. They look like elongated cells, widened at one end, where the nucleus and cilia are located. Cells of cylindrical ciliated epithelium are found in any sputum, however their increase testifies to damage to the bronchial mucosa and trachea (acute and chronic bronchitis, bronchiectasis, tracheitis, laryngitis).

Leukocytes in small amounts (2-5 in the field of vision) are found in any sputum. When inflammation of the lung tissue or bronchial mucosa and trachea, especially when suppuration (gangrene, lung abscess, bronchiectasis), their number is significantly increased.

When staining sputum preparations according to Romanovsky-Giemsa, it is possible to differentiate individual leukocytes, which sometimes has an important diagnostic value. Thus, with pronounced inflammation of the lung tissue or bronchial mucosa increases as the total number neutrophilic leukocytes, and the number of their degenerative forms with nuclear fragmentation and destruction cytoplasm.

An increase in the number of degenerative forms of leukocytes is the most important sign of the activity of the inflammatory process and the more severe course of the disease.

Erythrocytes. Single erythrocytes can be detected practically and any sputum. A significant increase is observed in the violation of vascular permeability in patients with pneumonia, in the destruction of lung tissue or bronchial tubes, stagnation in a small circle of blood circulation, lung infarction, etc. In a large number of red blood cells in sputum are found during hemoptysis of any genesis.

Elastic fibers. One more element of sputum plastic fibers that appear in sputum when destruction of lung tissue (lung abscess, tuberculosis, disintegrating lung cancer, etc.) should also be mentioned. Elastic fibers are presented in sputum in the form of thin two-contour, crimped filaments with dichotomous division at the ends. The appearance of elastic fibers in sputum in patients with severe pneumonia indicates the occurrence of one of the complications of the disease - abscessing of lung tissue. In some cases, in the formation of lung abscess, elastic fibers in sputum can be detected even slightly earlier than the corresponding radiographic changes.

Often, with croupous pneumonia, tuberculosis, actinomycosis, fibrinous bronchitis in sputum preparations, thin fibrin fibers can be detected.

Signs of an active inflammatory process in the lungs are:

1. the nature of sputum (mucopurulent or purulent);
2. an increase in the number of neutrophils in sputum, including their degenerative forms;
3. an increase in the number of alveolar macrophages (from single clusters of several cells in the field of view and more);

The appearance in the sputum of elastic fibers indicates the destruction of lung tissue and the formation of lung abscess.

The final conclusions about the presence and extent of the activity of inflammation and destruction of lung tissue are formed only with their comparison with the clinical picture of the disease and the results of other laboratory and instrumental methods research.

Microbial flora

Microscopy of sputum smears stained according to Gram, and the study of microbial flora (bacterioscopy) in part patients with pneumonia can tentatively determine the most likely causative agent of pulmonary infection. This simple method of express diagnostics of the pathogen is not accurate enough and should be used only in combination with other (microbiological, immunological) methods of sputum examination. Immersion microscopy of stained smears is sometimes very useful for emergency selection and administration of adequate antibiotic therapy. However, one should keep in mind the possibility of contamination of the bronchial contents of the microflora of the upper respiratory tract and oral cavity, especially when sputum collection is incorrect.

Therefore, sputum is considered suitable for further investigation (bacterioscopy and microbiological examination) only if it meets the following conditions:

• Gram staining in sputum reveals a large number of neutrophils (more than 25 in the field of view with a small magnification of the microscope);
• The number of epithelial cells, more characteristic of the contents of the oropharynx, does not exceed 10;
• in the preparation there is a predominance of microorganisms of the same morphological type.

When Gram staining in a smear of sputum, it is sometimes possible to identify well enough gram-positive pneumococci, streptococci, staphylococcus and a group of gram-negative bacteria - klebsiella, Pfeiffer's wand, E. coli and other In this case, Gram-positive bacteria acquire a blue color, and Gram-negative bacteria - red.

Bacterial pathogens of pneumonia

Gram-positive	Gram-negative
Pneumococcus Streptococcus pneumoniae. Streptococcus Streptococcus pyogenes, Streptococcus viridans. Staphylococci: Staphylococcus aureus, Staphylococcus haemolyticus.	Klebsiella pneumoniae Hemophilus influenzae (Pfeiffer) Haemophilius influenzae Pseudomonas aeruginosa Legionnella (Legionella Pneumophilia) E. coli (Escherichia coli)

Preliminary sputum smear is the simplest way to verify the causative agent of pneumonia and has definite implications for the selection of optimal antibiotic therapy. For example, when detected in smears stained by Gram, loud-positive diplococci (pneumococci) or staphylococci instead of broad-spectrum antibiotics, increasing the risk of selection and spreading of antibiotic-resistant microorganisms, it is possible to prescribe targeted therapy active against pneumococci or staphylococci. In other cases, the detection of the predominant Gram-negative flora in smears may indicate that the causative agent of pneumonia is Gram-negative enterobacteria (Klebsiella, Escherichia coli, etc.), which requires the appointment of an appropriate, purposeful therapy.

True, an approximate conclusion about a possible causative agent of pulmonary infection with microscopy can only be done on the basis of a significant increase in bacteria in sputum, in a concentration of 106- 107 m.ks / ml and more (L.L. Vishnyakova). Low concentrations of microorganisms (<103 m.ks / ml) are characteristic for the accompanying microflora. If the concentration of microbial bodies varies from 104 to 106 m.ks / ml, this does not exclude the etiological role of this microorganism in the onset of pulmonary infection, but it does not prove it.

It should also be remembered that "atypical" intracellular pathogens (mycoplasma, legionella, chlamydia, rickettsia) do not stain Gramm. In these cases, suspicion of having an "atypical" infection can occur if smear show a dissociation between a large number of neutrophils and an extremely small amount of microbial cells.

Unfortunately, the method of bacterioscopy is generally quite low in sensitivity and specificity. Not predictive value, even for well-visualized pneumococci, barely reaches 50%. This means that in half the cases the method gives false positive results. This is due to several reasons, one of which is that about 1/3 of the patients before the hospitalization have already received antibiotics, which significantly reduces the effectiveness of sputum smear-microscopy. In addition, even in the case of positive results of the study, indicating a sufficiently high concentration in the smear of "typical" bacterial (eg pneumococci), the presence of co-infection by "atypical" intracellular pathogens (mycoplasma, chlamydia, legionella).

The method of bacterioscopy of sputum smears, stained by Gram, in some cases helps to verify the causative agent of pneumonia, although it generally has very low predictive value. Atypical intracellular pathogens (mycoplasma, legionella, chlamydia, rickettsia) are not verified at all by the method of bacterioscopy, since they do not stain Gramm.

It should be mentioned the possibility of microscopic diagnosis in patients with pneumonia of fungal lung infection. The most relevant for patients receiving long-term treatment with broad-spectrum antibiotics is detection with microscopy of native or stained sputum preparations Candida albicans in the form of yeast-like cells and branchy mycelium. They indicate a change in the microflora of the tracheobronchial contents, which occurs under the influence of antibiotic treatment, which requires a substantial correction of therapy.

In some cases in patients with pneumonia, there is a need to differentiate the existing lung disease with tuberculosis. For this purpose, the color of the sputum smear according to Tsiol-Nielsen is used, which in some cases allows one to identify Mycobacterium tuberculosis, although the negative result of such a study does not mean the absence of a patient tuberculosis. When staining sputum according to Tsiol-Nielsen, mycobacterium tuberculosis is colored red, and all other sputum elements are blue. Tuberculous mycobacteria have the appearance of feces, straight or slightly curved sticks of different lengths with separate thickenings. They are located in the preparation in groups or singly. Diagnostic value is the detection in the preparation of even single mycobacteria tuberculosis.

To increase the effectiveness of microscopic detection of mycobacteria tuberculosis use a number of additional methods. The most common of these is the so-called flotation method, in which a homogenized Sputum is shaken with toluene, xylene or gasoline, the drops of which, while floating up, capture mycobacteria. After settling the sputum, the top layer is pipetted onto a piece of glass. Then the drug is fixed and stained by Tsilyu-Nielsen. There are other methods of accumulation (electrophoresis) and microscopy of tuberculosis bacteria (luminescence microscopy).

Microscopic examination (analysis) of mucus allows to detect mucus, cellular elements, fibrous and crystalline formations, fungi, bacteria and parasites.

Cells

• Alveolar macrophages are cells of reticulogistocyte origin. A large number of macrophages in sputum is detected in chronic processes and at the stage of resolving acute processes in the bronchopulmonary system. Alveolar macrophages containing hemosiderin ("cells of cardiac defects") are detected with a mild infarct, hemorrhage, stagnation in a small circle of circulation. Macrophages with lipid droplets are a sign of obstructive process in the bronchi and bronchioles.
• Xantom cells (fatty macrophages) are found in abscess, actinomycosis, echinococcosis of the lungs.
• Cells of the cylindrical ciliated epithelium are cells of the mucous membrane of the larynx, trachea and bronchi; they are found in bronchitis, tracheitis, bronchial asthma, malignant neoplasms lungs.
• The flat epithelium is detected when spittle enters the sputum, it has no diagnostic significance.
• Leukocytes in one or another quantity are present in any sputum. A large number of neutrophils are detected in mucopurulent and purulent sputum. Eosinophils are rich in sputum in bronchial asthma, eosinophilic pneumonia, glottis lung lesions, and lung infarction. Eosinophils may appear in sputum for tuberculosis and lung cancer. Lymphocytes in large numbers are found in whooping cough and, more rarely, with tuberculosis.
• Erythrocytes. Detection of single red blood cells in sputum is not of diagnostic significance. In the presence of fresh blood in the sputum, unchanged erythrocytes are determined, if the phlegm leaves blood that has been in the airways for a long time reveals leached erythrocytes.
• Cells of malignant tumors are found in malignant neoplasms.

Fibers

• Elastic fibers appear in the decay of lung tissue, which is accompanied by the destruction of the epithelial layer and release of elastic fibers; they are found in tuberculosis, abscess, echinococcosis, neoplasms in lungs.
• Coronal fibers are detected in chronic lung diseases, such as cavernous tuberculosis.
• Calcined elastic fibers are elastic fibers impregnated with calcium salts. Detection of them in sputum is characteristic for the breakdown of tubercular petrichitis.

Spirals,crystals

• Kurshman spirals are formed in the spastic state of the bronchi and the presence of mucus in them. During a cough thrust, viscous mucus is released into the lumen of a larger bronchus, twisting in a spiral. Kurshman spirals appear with bronchial asthma, bronchitis, lung tumors, compressing bronchi.
• The Charcot-Leiden crystals are the products of the decay of eosinophils. Usually appear in a sputum containing eosinophils; are characteristic for bronchial asthma, allergic conditions, eosinophilic infiltrates in the lungs, pulmonary flukes.
• Cholesterol crystals appear with abscess, lung echinococcosis, neoplasms in the lungs.
• Crystals of hematoidin are characteristic for abscess and gangrene of the lung.
• Druses of actinomycete are detected in the actinomycosis of the lungs.
• Elements of echinococcus appear with echinococcosis of the lungs.
• Corks Dietrich - lumps of a yellowish-gray color, having an unpleasant smell. They consist of detritus, bacteria, fatty acids, droplets of fat. They are typical for an abscess of lung and bronchiectasis.
• Ehrlich's tetrad consists of four elements: calcified detritus, calcified elastic fibers, cholesterol crystals and mycobacterium tuberculosis. Appears in the decay of the calcified primary tubercular focus.

Mycelium and budding fungal cells appear in fungal lesions of the bronchopulmonary system.

Pneumocystis occurs with pneumocystis pneumonia.

Spherules of fungi are detected in coccidioidomycosis of the lungs.

The ascarid larvae are detected with ascariasis.

Larvae of the intestinal ugristic are identified with strongyloidiasis.

Eggs of the pulmonary fluke are identified with paragonimosis.

Elements found in sputum in bronchial asthma. When bronchial asthma is usually separated by a small amount of mucous, viscous sputum. Macroscopically you can see the Kurshman spiral. When microscopic research is characteristic of the presence of eosinophils, cylindrical epithelium, there are crystals of Charcot-Leiden.

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