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.

Relatively small amount of sputum (no more than 50-100 ml per day) is typical for the majority of patients with pneumonia and other inflammatory diseases of the lungs (acute tracheitis, acute and chronic bronchitis, etc.).

A significant increase in the amount of sputum (more than 150-200 ml per day) is usually observed in diseases accompanied by the formation of a cavity communicating with the bronchus (lung abscess, tuberculous cavern, bronchiectasis), or tissue decay (gangrene, decaying lung cancer, ). 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 the enzyme verdoperoxidase, the transformation of the iron-porphyrin group of which causes a greenish tinge of 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 main pathological process (catarrhal, purulent or fibrinous inflammation, tumor, etc.), significantly changes the color of sputum (see 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 increasing the permeability of the vascular wall, 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 as a foamy liquid, sometimes diffusely colored pink, which indicates a significant increase in permeability of the vascular wall and bleeding by per diapidesum type.
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 upper layer of such sputum consists of a foamy colorless mucus containing a large number of air bubbles, the middle one - from a muddy 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 the damage to the lung tissue and respiratory tract, the admixture of blood in the sputum (haematoptoe) may be different: 1) blood veins, 2) blood clots, 3) rusty sputum, 4) diffusely colored pink sputum and t .P. If clear red blood is excreted in the expectoration without an admixture of mucus or pus, they speak of the onset of 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 in focal and influenza pneumonia, with lung tuberculosis with curdled decay, stagnation in the lung, swelling of the lung, and the like. On the other hand, with croupous pneumonia, sputum or blood clots can sometimes 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.

[1], [2], [3], [4], [5], [6],