Lab Test Procedure : Respiratory Specimen Collection

Nasal Culture

Equipment
ESwab, mini-tip collection kit


Insert the swab into a nares until resistance is met at the level of the turbinate. Rotate the swab against nasal mucosa. Break swab off into the transport tube containing 1.0mL of liquid media, send to laboratory.


Nasal Smear for Eosinophils

Equipment
One glass slide (available from Micro-Processing in the laboratory)
waxed paper or plastic wrap
ESwab mini-tip collection kit (green capped) or nasal aspirator
Gloves


Obtain mucous sample by one of three methods:
1. Have the child blow his nose into waxed paper or plastic wrap.
2. Insert nasal aspirator into one side of the nose and obtain specimen.
3. Use NPH wire swab: Place the swab near the septum and on the floor of the nose. Keep the swab in place for 30 seconds and then remove.

Apply a generous smear of mucous by rolling swab or specimen onto a glass slide. Avoid rubbing swab against the slide because friction increases the eosinophil count. Allow to dry.

Place the dry slide into a cardboard slide envelope. Tape the envelope shut with clear tape and send to the Laboratory.



Nasal Wash for Rapid RSV or Rapid Influenza, Adenovirus, or Parainfluenza virus antigen detection or viral culture.

Equipment
Sterile normal saline (NS) for irrigation
luki-trap
suction catheter
gloves
M4 (VIRAL TRANSPORT MEDIA-VTM)medium


1. Have the patient clear any nasal congestion before obtaining the specimen by blowing his nose or by nasal suctioning.
2. Connect the suction catheter to the luki-trap and then connect the luki-trap to wall suction.
3. "Wash" for nasal cells by irrigating both nares with 0.5 mL normal saline. Suction each nares to obtain cells not mucus.
4. Rinse the suction catheter with 1.0-1.5 mL normal saline which helps move the specimen from the suction catheter into the luki-trap.

Place 0.5mL of saline wash into M4 (VIRAL TRANSPORT MEDIA-VTM)medium and send both the nasal wash and dilute M4(VIRAL TRANSPORT MEDIA-VTM) specimens to the laboratory.

If using a bulb syringe,empty contents of the bulb syringe directly into sterile container. Place 0.5 mL into M4 medium for back-up culture and send both the nasal wash and the M4 diluted specimen on ice to the laboratory for testing.

NOTE: Do not add M4 viral medium to the specimen. The M4 (VIRAL TRANSPORT MEDIA-VTM) must be sent on ice. Send directly to Laboratory.

Special Instructions The saline wash specimen is used for the direct antigen assay. A portion of the specimen must be placed in M4 (VIRAL TRANSPORT MEDIA-VTM) as it protects the viability of the virus for a back up viral culture should the direct antigen assay be negative.



Nasopharyngeal (NPH)

Equipment
Rapid RSV, Rapid Influenza, Adenovirus, Parainfluenza virus
2 NPH flocked swabs
M4 (VIRAL TRANSPORT MEDIA-VTM)


NPH culture for N. meningitis or other bacteria
ESwab minitip collection kit(green capped)


NPH for Bordetella pertussis
1 NPH flocked swab or NPH wire swab (green capped)
Do not place in M4 (VIRAL TRANSPORT MEDIA-VTM))


Specimen Collection (NPH culture and/or B. Pertussis)
1. Hold the child securely. Remove a swab from the culturette. Slide the swab into the nares to the posterior nasopharynx.
2. Leave swab in place 20-30 seconds or as tolerated. Withdraw the swab.
3. Repeat the process on the other nares with a second swab. Replace the swab into the culturette. For pertussis PCR, only one swab is used to culture both nares.

Specimen Collection (Rapid RSV, Rapid Influenza, Adenovirus, and Parainfluenza virus)
1.Two flocked swabs should be collected.
2. Slide flocked swab into the nares to the posterior nasopharynx (at base of throat). Rotate the swab and allow 5-10 seconds for liquid to absorb.
3. The first swab can be placed back into the culturette and sent for rapid testing.
4. Repeat collection with the second flocked swab. The second flocked swab is broken off into M4 (VIRAL TRANSPORT MEDIA-VTM). This specimen will be used for the back-up respiratory virus isolation culture if the rapid test is negative.



Sputum

Equipment
sterile cup (clear plastic screw cap)

1. Collect specimen resulting from a deep cough into sterile cup. Notify the physician if unable to obtain specimen.
2. A specimen may be obtained by sterile suction technique using a Luki-trap by passing a sterile suction catheter along floor of nose to nasopharynx. When the patient coughs, suction the specimen into trap. Obtain specimen by suction only with physician order.
3. Twenty-four hour sputum collections are not recommended for culture. If possible, have the patient rinse mouth and gargle with water prior to sputum collection. Instruct the patient not to spit saliva or postnasal discharge into the container. A gram stain smear result on sputum specimens will show epithelial cells. A sputum specimen containing >25 epithelial cells per low power field has been contaminated with oropharyngeal secretions during collection, indicating a poor quality specimen for culture. Laboratory may indicate the need for specimen recollection. Laboratory evaluates the specimen for the predominant pathogenic morphotype if the physician requests a culture on available specimen.
4. Sputum (acid fast bacili or mycobacteria) First morning sputum samples of 3.0-5.0 mL is optimal for possible recovery of mycobacterial organisms. Acid fast stain performed on all sputum specimens.



Tracheostomy Culture

Equipment
Luki trap
sterile gloves
sterile suction catheter
Sterile normal saline
Luki trap tubes
disposable clean graduated cup
Audit trail and label


1. Connect suction catheter to rubber tubing side on aspirating trap and connect the other side of aspirating trap to the tubing from wall suction.
2. Draw up the appropriate amount of preservative free sterile saline for irrigation into a syringe. Under 1 year: 0.5mL; 1-3 years: 1 mL; 3 years and older: 2mL. Pour the remaining normal saline for irrigation into graduated cup.
3. Suction the patient by putting on sterile gloves, instilling saline from syringe (without needle), suction patient while keeping the aspirating trap in a vertical position.
4. If the specimen is in the catheter, suction a small amount of normal saline for irrigation from graduated cup to move secretions into aspirating trap. Disconnect aspirating trap from suction tubing and catheter. Connect tubing on aspirating trap to other side of the trap.



Throat (Pharyngeal)

Equipment
Tongue depressor
Group A antigen test (rapid) and culture: Rayon dual swab
Throat culture for GC only: ESwab collection kit
Routine culture(Haemophilus influenza, Strep pneumoniae): ESwab collection kit
NOTE: Do not obtain throat cultures if the epiglottis is inflamed. Sampling may cause serious respiratory obstruction.

1. Remove the swab from the collection kit package.
2. Depress tongue gently with tongue depressor.
3. Visualize throat area for obvious purulent areas. Swab between the tonsillar pillars and behind the uvula. Avoid touching the cheeks, tongue, uvula or lips.
4. Swab back and fourth across the posterior pharynx, tonsillar area and any inflamed or ulcerated areas to obtain sample.

Transport
For Group A Strep antigen test and Strep culture: Replace the two swab specimens in the culturette. When group A Strep antigen (rapid) test and culture are ordered, the antigen (rapid) test will be performed first. If the result is positive, the culture will not be processed and the patient will not be charged for the culture. If the antigen (rapid) test is negative, a culture should be ordered and completed.
For throat GC culture and routine culture: the swab is broken off into the tube containing 1.0mL liquid media and sent to the laboratory.


References:
Bowden, V.R., Smith Greenberg, C.(2008). Pediatric Nursing Procedures, 2nd Ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Isenbery, H.D. (2004). Clinical Microbiology Procedures Handbook, Volume 2. Washington, D.C.: The ASM Press.



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