The first step in the management of the lung cancer suspect after the initial x-ray films are taken should not be bronchoscopy or further x-ray studies but rather the procurement of sputum for cytologic examination.

Why this insistence on the dominant role of cytology? The reasons are as follows:

1. Simplicity. In the case of the patient with a productive cough, it is often possible to obtain a good specimen in the office or laboratory on the first visit. This failing, he can be provided with containers for sputum collection over the next three days. Even in the case of the patient without a productive cough it is now possible to obtain good sputum by means of a new technique described below.

2. Speed. This aspect of cytology has been implied previously. With adequate laboratory facilities at hand, a report can be available within a few days after the patient is first seen.

3. Expense. A series of three sputum specimens can be processed at a cost only slightly more than that entailed in obtaining posteroanterior and lateral x-ray films of the chest.

4. Sensitivity. Sputum cytology can be expected to yield a positive diagnosis over twice as often as bronchoscopy alone; i.e., over 80% of lung cancer patients will show a positive cytology if at least three adequate specimens are submitted.

5. Reliability. In experienced hands, a false positive cytology report is extremely uncommon-at least as rare as a false positive biopsy report.

Management Of The Patient Producing Sputum. In The Office

It is important that the patient be instructed in how to provide a proper sputum specimen. A few moments devoted to this indoctrination will keep to a minimum those specimens which consist mostly of saliva and the products of chronic sinusitis, postnasal drip, etc. The latter are worse than useless for diagnostic purposes. The product of a deep cough will usually provide representative material for analysis. Before the patient leaves the office, it is wise for the physician or his aide to give the patient a bottle containing 50% alcohol and to observe him while he attempts to provide a specimen. Often this attempt will be successful, and the first sample can be submitted for study. If it is unsuccessful, at least the patient will have the proper technique mastered for repetition at home.

In The Home

The patient should be provided with enough bottles of 50% alcohol to ensure submission of at least three representative specimens to the cytology laboratory. The bottles should be kept within easy reach and the products of all deep coughs deposited in them. Normally, each bottle is used to collect a twenty-four hour specimen, but if sputum production is copious, the results of the first early morning paroxysm may be enough. The bottles should then be returned promptly to the doctor's office or directly to the cytology laboratory. One of the virtues of this approach is that other diagnostic studies can be proceeding concurrently and consequently no time is lost.

If more convenient, the sputum can be collected in clean, dry, glass containers provided 50% alcohol is added within a period of three hours.

Management Of The Patient Not Producing Sputum

Until relatively recently there was no means of sampling the exfoliated cellular material of the tracheobronchial tree in the patients without a productive cough. They were usually subjected to bronchoscopy with bronchial washings as one of the first diagnostic approaches. Now it is possible and relatively simple to provoke a productive cough in almost any individual and to obtain material for cytologic examination at the time of the first visit.

The Aerosol Technique Or Sputogenic Machine Background

The aerosol method of promoting sputum production is based on techniques developed by Barach and associates. It involves the use of a solution of sodium chloride and propylene glycol warmed in a heated nebulizer and vaporized by means of an air pump or oxygen cylinder. The patient inhales this mist and then experiences the urge to cough, usually producing a good specimen in a matter of minutes. The procedure is simple and well tolerated by most patients. Caution must be exercised in patients with asthma and emphysema.

Technique

1. The equipment required is represented in Fig. 44, A. The solution used is composed of 15% sodium chloride and 20% propylene glycol.*

2. Allow the solution to heat from five to ten minutes (vapor at the mouthpiece will then register in the range of 120° F.).

3. Seat the patient in front of the machine with his mouth one half inch from the mouthpiece (Fig. 44, B).

4. Patients with postnasal drip, etc. are encouraged to rid themselves of secretions now.

*Formula: 150 Cm. sodium chloride; 200 Cm. propylene glycol; qs ad 1000 ml. distilled water. A stock solution for use in the office can be prepared by any pharmacy.

Fig. 44. Set-up for the aerosol method of promoting sputum production.

Patients with asthma, emphysema, etc. may be given a few whiffs of a bronchodilator such as Vaponephrin or Isuprel at this point, or these agents may be held in reserve for use only as needed. All patients should be provided with a kidney basin or similar receptacle and told to use it to keep the mouth and throat as free as possible of saliva, etc., during inhalation.

5. The patient is told to inhale through his mouth at normal rate and depth, maintaining at all times a distance of one-half inch from the mouthpiece (Fig. 44, B). Some physicians report a more satisfactory and rapid response by inserting the mouthpiece in the patient's mouth.

6. Normal response is a deep and involuntary cough, usually in the first several minutes of inhalation, although the time may range from one to twenty minutes.

7. If there is no evidence of a cough at the end of five minutes, the patient is instructed to take a breath and to hold it and to repeat this once a minute.

8.If there is no response at the end of the second five-minute period, the patient is encouraged to induce a deep cough. This will usually produce sputum. If unsuccessful on the first attempt, this maneuver may be repeated once or twice.

9. If a patient does not demonstrate a productive cough after twenty minutes, the procedure is discontinued. This should prove necessary in less than 10 to 20% of patients.

10. Any sputum produced should be expectorated into a bottie containing 30 ml. of 50% alcohol (Fig. 44, B). It is wise and usually possible to collect two different specimens from each individual. The botde should be labeled with the patient's name, the date the specimen is obtained, and the date the specimen is submitted to the laboratory. If previous specimens have been studied, this information should be given the cytologist.

11. The appearance of the specimen as it enters the alcohol may assist in deciding on the spot whether it is likely to be a good one.