An overview of

PULMONARY TUBERCULOSIS

Etiology and Pathophysiology

-Common Causative Agent: Mycobacterium tuberculosis
·Aerobic bacterium that divides every 16 to 20 hours
·Gram (+)
·Rod-like bacillus that can withstand weak disinfectants and survive in a dry state
for weeks
·Acid-fast bacillus

M. tuberculosis complex includes three other TB-causing mycobacteria:

•M. africanum is not widespread, but in parts of Africa it is a significant cause of
tuberculosis.
•M. bovis was once a common cause of tuberculosis, but the introduction of
pasteurized milk has largely eliminated this as a public health problem in developed
countries.
•M. microti is mostly seen in immunodeficient people, although it is possible that
the prevalence of this pathogen has been underestimated.

Transmission:
The most common transmission is HUMAN to HUMAN. The predominant medium through
which TB is spread is air. Mucus droplets containing the bacteria are released from an
infected individual when they perform any type of forceful expiratory effort. These particles
remain suspended in the air and, once inhaled by a susceptible person, they can
cause infection inside the lungs. TB infection begins when the mycobacteria reach the
pulmonary alveoli. The course of the infection initially presents as a primary infection
which causes inflammation in a small area within the lung and is usually self-limiting.
The primary site of infection in the lungs is called the Ghon focus
 upper part of the lower lobe or the lower part of the upper lobe
 Bacteria are picked up by dendritic cells.
 These cells can transport the bacilli to lymph nodes.
Further spread is through the bloodstream to other tissues and organs where secondary
TB lesions can develop in other parts of the lung, peripheral lymph nodes, kidneys, brain,
and bone.
It takes 4-12 weeks after being infected for the primary infection to arise.
The body’s reaction to the infection is a cell-mediated immune response. This response is
usually adequate to control the infection, but may not eliminate all bacteria. The remaining
bacteria resolve into a calcified lesion where they are housed during a latent period.
In a small number of cases, the infection may not become inactive (latent) after the primary
infection and may progress to a more destructive chronic form of primary TB.
Complications:
•Extrapulmonary tuberculosis (TB spread to areas of the body outside of the lungs)
•Tuberculosis pneumonia (massive lobular or lobar pneumonia)
•Pleuritis (infection & inflammation of tissue covering the lungs)

Signs and Symptoms:

•Chest pain
•Coughing up blood
•Productive, prolonged cough for more than three weeks
Systemic symptoms:
•Fever •Appetite loss •And often a
•Chills •Weight loss tendency to
•Night sweats •Pallor fatigue

Diagnosis:
•Chest X-ray
•In active pulmonary TB, infiltrates or cavities are often seen in the upper lungs with or
without mediastinal or hilar lymphadenopathy or pleural effusions ( tuberculous pleurisy).
However, lesions may appear anywhere in the lungs.
•Abnormalities on chest radiographs may be suggestive of, but are never diagnostic of,
TB. However, chest radiographs may be used to rule out the possibility of pulmonary TB in
a person who has a positive reaction to the tuberculin skin test and no symptoms of
disease.

•Mantoux Skin Test

•A standard dose of 5 Tuberculin units (0.1 mL) is injected intradermally and read 48 to 72
hours later. A person who has been exposed to the bacteria is expected to mount an
immune response in the skin containing the bacterial proteins.
•The reaction is read by measuring the diameter of induration (palpable raised hardened
area) across the forearm in millimeters. If there is no induration, the result should be
recorded as "0 mm". Erythema (redness) should not be measured.

•Classification of tuberculin reaction:

•5 mm or more
•Positive in HIV-positive person
•Recent contacts of TB case
•Persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB
•Patients with organ transplants and other immunosuppressed patients
•10 mm or more
•Positive in Recent arrivals from high-prevalence countries
•Injection drug users
 •Residents and employees of high-risk congregate settings (e.g., prisons, nursing
homes, hospitals, homeless shelters, etc.)
•Mycobacteriology lab personnel
•Persons with clinical conditions that place them at high risk (e.g., diabetes,
prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic
malabsorption syndromes, low body weight, etc)
•Children less than 4 years of age, or children and adolescents exposed to adults in
high-risk categories
•15 mm or more
•Persons with no known risk factors for TB

•Sputum cultures
-should be done for acid-fast bacilli if the patient is producing sputum. The preferred
method for this is fluorescence microscopy (auramine-rhodamine staining), which is more
sensitive than conventional Ziehl-Neelsen staining.
Why it is done?
•To detect and identify the bacteria or fungi that are causing an infection of the lungs or the
airways leading to the lungs.
•Identify the best antibiotic to treat the infection.
•Monitor treatment of an infection.
How To Prepare?
•Do not use mouthwash before collecting a sputum sample because it may contain
antibacterial substances that could affect your results.
•If bronchoscopy will be used to collect your sputum sample, do not drink or eat for 6 hours
before having the test.
•Tell your health professional if you have recently taken any antibiotics.
How It Is Done?
•Usually, the sputum sample is collected early in the morning before you eat or drink
anything.
•The health professional collecting the sample may tap on your chest to help loosen the
sputum in your lungs before you cough.
•Once the sputum sample is collected, it will be placed in a container with the culture
medium that promote the growth of infecting organisms.
•The organism that causes tuberculosis may take 6 weeks to grow.
•Any bacteria or fungi that grow will be identified under a microscope or by chemical
tests.
•Sensitivity testing, to determine the best antibiotic to use against the organism that
grows, often takes 1 to 2 additional days.

Prevention:
•Bacillus Calmette Guérin (BCG)
-is a vaccine against tuberculosis that is prepared from a strain of the attenuated
(weakened) live bovine tuberculosis bacillus.
•Prompt diagnosis and treatment of infectious cases
•Educate the public in the mode of spread and methods of control and the importance of
early diagnosis
•Improve social conditions which increase the risk of becoming infected such as
overcrowding
•Make available medical, laboratory and x-ray facilities for examination of patients and
facilities for early treatment of cases.

Treatment:
•Short course regimen with at least 3 anti-TB drugs for 2 months during the intensive
phase and 2 anti-TB drugs for 4 months during the continuation phase
•Domiciliary treatment shall be the preferred mode of care.

Anti-TB Drugs
•Isoniazid (INH) is an organic compound that is the first-line anti-tuberculosis medication in
prevention and treatment. Isoniazid is never used on its own to treat active tuberculosis
because resistance quickly develops.
•Rifampicin is a bactericidal antibiotic drug
•Pyrazimide is largely bacteriostatic but can be bacteriocidal on actively replicating
tuberculosis bacteria.
•Ethambutol is a bacteriostatic antimycobacterial drug prescribed to treat tuberculosis
•Streptomycin - it kills sensitive microbes by inhibiting protein synthesis

NCP of TB patients
•Assessment
Subjective Cues:
•As verbalized, the patient is experiencing difficulty in breathing.
Objective
•Crackling sound heard •Unproductive cough
upon lung auscultation •Weak
•Intermittent cough noted •RR = 24bpm
•Diagnosis
•Ineffective airway clearance related to retained secretions secondary to PTB
•Risk for infection
•Risk for impaired gas exchange
•Imbalanced nutrition
•Deficient knowledge
•Planning
Within 8 hours spam, patient will be able to:
•Expectorate secretions
•Demonstrate interventions such as deep breathing
•Interventions
•Auscultated breath sounds and assessed air movement to ascertain status and note
progress.
•Elevate the head of the bed/change position every 2 hours and PRN to take advantage of
gravity decreasing pressure on the diaphragm and enhancing drainage of ventilation to
different lung segments
•Encouraged deep breathing and coughing exercise
•Encouraged increase fluid intake
•Provided supplemental humidification if needed
•Provided back tapping after nebulization to move the secretions in the lungs

Abarado, Jose Benjamin

Aduca, Joanne Camille
Ampalayo, Lear Kenneth
BSN – 2B