Efficacy of sputum induction from lower respiratory tract in children

Main Article Content

Madeleine Ramdhani Jasin
Darmawan Budi Setyanto
Sri Rezeki Hadinegoro
Lisnawati Lisnawati
Pramita Gayatri
Nia Kurniati


Background Although sputum is a good specimen for various
examinations, such as cytology and microbiological culture,
sputum induction (SI) is not a routine procedure in children.
Objective To identify the efficacy of SI to obtain specimen from
lower respiratory tract in children, identify side effects of SI, and
the results of microbiological examination.
Methods A cross sectional study was performed in children (aged
1 month to 18 years) who underwent SI. Sputum induction was
performed by inhalation with hypertonic solution, consisted of
salbutamol for 15 minutes continued with NaCl 3% solution
for another 15 minutes. Sputum specimens were examined for
number of alveolar macrophage cell, surfactant protein A (SP-A)
concentration, also acid-fast bacili smear, and M. tuberculosis
culture, or aerobic microbial culture.
Results Forty subjects with lower respiratory tract infection
participated in this study, and SI was succesfully performed in
all subjects. Youngest subject was 2 month old, the eldest was 16
year 7 month old. Median duration of SI was 45 minutes, and
majority of volume was 3 or 4 mL. Side effects were nosebleeds
(40%) and vomiting (2.5%). Macrophage alveolar more than 5
cells in one specimen was found in 97.5% subjects. Surfactant
protein A examination was performed in 30 specimens, and SP-A
was detected in all specimens (median concentration 264.528 pg/
mL). Culture for M. tuberculosis was positive in 1 of 27 subjects,
while acid fast bacili smear was negative in all examined subjects.
Aerobic microbial culture was positive in 5 of 13 subjects.
Conclusions Sputum induction has good efficacy in obtaining
lower respiratory tract specimen and it is safe to perform in
children. Specimen from sputum induction yields good positive
result for aerobic microbial cultures.

Article Details

How to Cite
Jasin MR, Setyanto DB, Hadinegoro SR, Lisnawati L, Gayatri P, Kurniati N. Efficacy of sputum induction from lower respiratory tract in children. PI [Internet]. 30Apr.2015 [cited 23Sep.2020];55(2):101-. Available from: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/94
Received 2016-06-29
Accepted 2016-06-29
Published 2015-04-30


1. Giles TE, Mccarthy J, Gray W. Respiratory tract. In: Gray W, Kocjan G, editors. Diagnostic cytopathology. Philadelphia: Elsevier; 2010. p.17–111.
2. Elkins MR, Lane T, Goldberg H, Pagliuso J, Garske LA, Hector E, et al. Effect of airway clearance techniques on the efficacy of the sputum induction procedure. Eur Respir J. 2005;26:904–8.
3. Grant LR, Hammitt LL, Murdoch DR, Brien KLO, Scott JA. Procedures for collection of induced sputum specimens from children. Clin Infect Dis. 2012;54:S140–5.
4. Pritt BS, Yao JDC. Microbiologic diagnosis of lower respiratory tract infection. In: Mason RJ, Boarddus VC, Martin T, King Jr T, Schraufnagel D, Murray JF, et al, editors. Murray and Nadel’s textbook of respiratory medicine. Philadelphia: Elsevier Inc.; 2010. p. 368–92.
5. Zar HJ, Hanslo D, Apolles P, Swingler G, Hussey G. Induced sputum versus gastric lavage for microbiological confirmation of pulmonary tuberculosis in infants and young children: a prospective study. Lancet. 2005;365:130–5.
6. Araújo L, Moreira A, Palmares C, Beltrão M, Fonseca J, Delgado L. Induced sputum in children: success determinants, safety, and cell profiles. J Investig Allergol Clin Immunol. 2011;21:216–21.
7. Gibson PG, Henry RL, Pin I, Rytilla PH, Wark P, Wilson N, et al. Sputum induction in children. Eur Respir J. 2002;20:44s– 46s.
8. Nicholas B, Djukanovi R. Induced sputum: a window to lung pathology. Biochem Soc Trans. 2009;37:868–72.
9. Kips JC, Inman MD, Jayaram L, Bel EH, Parameswaran K, Pizzichini MMM, et al. The use of induced sputum in clinical trials. Eur Respir J. 2002;20:47s – 50s.
10. French CA. Respiratory tract. Dalam: Cibas E, Ducatman B, editors. Cytology. Philadelphia: Elsevier; 2009. p. 65–103.
11. Said M, Daulay R, Naning R, Dadiyanto DW. Induksi Sputum. In: Rahajoe NN, Supriyanto B, Setyanto DB, editors. Buku ajar respirologi anak. Jakarta: Ikatan Dokter Anak Indonesia; 2008. p. 583–612.
12. Pavord ID, Pizzichini MMM, Pizzichini E, Hargreave FE. The use of induced sputum to investigate airway inflammation. Thorax. 1997;52:498–501.
13. Zar HJ, Tannenbaum E, Hanslo D, Hussey G. Sputum induction as a diagnostic tool for community-acquired pneumonia in infants and young children from a high HIV prevalence area. Pediatr Pulmonol. 2003;62:58–62.
14. Moore HA, Apolles P, Villiers PJT De, Zar HJ, Clinic K, Town C, et al. Sputum induction for microbiological diagnosis of childhood pulmonary tuberculosis in a community setting. Int J Tuberc Lung Dis. 2011;15:1185–90.
15. Li AM, Tsang TWT, Chan DFY, Lam HS, So HK, Sung RYT, et al. Sputum Induction in children with asthma: a tertiary center experience. Pediatr Pulmonol. 2006;41:720–5.
16. Pizzichini MMM, Leigh R, Djukanovic R, Sterk PJ. Safety of sputum induction. Eur Respir J. 2002;20:9s – 18s.
17. Elkins M. Sputum induction - current practice in Australia & New Zealand. Respirology. 2002;7:A63–5.
18. Paggiaro PL, Chanez P, Holz O, Ind PW, Djukanovic R, Maestrelli P, et al. Sputum induction. Eur Respir J. 2002;20:3s–8s.
19. Rahajoe NN, Setyanto DB. Diagnosis tuberkulosis pada anak. In: Rahajoe NN, Supriyatno B, Setyanto DB, editors. Buku ajar respirologi anak. 1st edition. Jakarta: IDAI; 2012. p.194-213.
20. Gershman NH, Liu H, Wong HH, Liu JT, Fahy J V, Francisco S. Fractional analysis of sequential induced sputum samples during sputum induction: Evidence that different lung compartments are sampled at different time points. J Allergy Clin Immunol. 1999;104:322–8.
21. Alexis NE, Hu S, Zeman K, Alter T, Bennett WD. Induced sputum derives from the central airways confirmation using a radiolabeled aerosol bolus delivery technique. Am J Respir Crit Care Med. 2001;164:1964–70.
22. Pizzichini GE. Safety of sputum induction. Eur Respir J. 2002;20:9–18.
23. Chen D, Zhong G, Luo W, Chen Q, Sun B, Lin Y, et al. Reference values of induced sputum cytology in healthy children in Guangzhou, Southern China. Pediatrics. 2013;131:e518–24.
24. Papanicolaou Society of Cytopathology Task Force on Standards Practice. Guidelines of the Papanicolaou Society of cytopathology for the examination of cytologic specimens obtained from the respiratory tract. Diagn Cytopathol. 1998;21:61–9.
25. Strayer D, Yang S, Jerng HH. Surfactant protein A-binding proteins. J Bio Chem. 1993;268:18679–84.
26. Khubchandani KR, Snyder JM, Sp-a A, Faseb J. Surfactant protein A (SP-A): the alveolus and beyond. FASEB J. 2001;15:59–69.
27. Kim JK, Kim S, Rha KW, Kim C, Cho JH, Lee C, et al. Expression and localization of surfactant proteins in human nasal epithelium. Am J Physiol Lung Cell Mol Physiol. 2007;752:879–84.
28. Oberley RE, George CLS, Snyder JM. A new tool to investigate differences between human SP-A1 and SP-A2. Am J Physiol Lung Cell Mol Physiol. 2007;292:1050–1.
29. Schicht M, Stengl C, Sel S, Heinemann F, Gotz W, Petschelt A, et al. The distribution of human surfactant protein within the oral cavity and their role during infectious disease of the gingiva. AANAT. 2014;14:128–9.
30. Wright SM, Hockey PM, Enhorning G, Strong P, Kenneth B, Reid M, et al. Altered airway surfactant phospholipid composition and reduced lung function in asthma. J Appl Physiol. 2000;89:1283–92.
31. Stevens P, Schadow B, Bartholain S, Segerer H, Obladen M. Surfactant protein A in the course of respiratory distress syndrome. Eur J Pediatr. 1992;151:596–600.
32. Griese M, Neumann M, von Bredow T, Schmidt R, Ratjen F. Surfactant in children with malignancies, immunosuppression, fever and pulmonary infiltrates. Eur Respir J. 2002;20:1284–91.
33. Sorensen GL, Husby S, Holmskov U. Surfactant protein A and surfactant protein D variation in pulmonary disease. Immunobiology. 2007;212:381–416.
34. Kishore U, Bernal AL, Kamran MF, Saxena S, Singh M, Sarma PU, et al. Surfactant proteins SP-A and SP-D in human health and disease. Arch Immunol Ther Exp. 2005;53:399–417.
35. Kuroki Y, Takahashi H, Chiba H, Akino T. Surfactant proteins A and D: disease markers. Biochim Biophys Acta. 1998;1408:334–45.
36. Mukherjee A, Singh S, Lodha R, Singh V, Hesseling AC, Grewal HMS, et al. Ambulatory gastric lavages provide better yields of Mycobacterium tuberculosis than induced sputum in children with intrathoracic tuberculosis. Pediatr Infect Dis. 2013;32:1313–7.
37. Swaminathan S, Padmapriyadarsini C, Narendran G. HIV associated tuberculosis: clinical update. Clin Infect Dis. 2010;50:1377–86.
38. Said M. Pneumonia. Dalam: Rahajoe NN, Supriyatno B, Setyanto DB, editors. Buku ajar respirologi anak. Jakarta: Ikatan Dokter Anak Indonesia; 2008. p. 350–65.
39. Ruuskanen O, Waris M. Viruses and bacteria in sputum samples of children with community-acquired pneumonia. Clin Microbiol Infect. 2012;18:300–7.
40. Lahti E, Peltola V, Waris M, Virkki R, Jalava J, Eerola E, et al. Induced sputum in the diagnosis of childhood community acquired pneumonia. Thorax. 2009;64:252–7.
41. Brooks GF, Butel JS, Ornston LN, Jawetz E, Melnick JL, Adelberg EA, editors. Flora mikroba normal tubuh manusia. In: Mikrobiologi kedokteran. Jakarta: Penerbit Buku Kedokteran EGC; 1996. p. 188–92.