Pulmonary Tuberculosis

I. Definition
- is a common and often deadly infectious disease caused by various strains
of mycobacteria, usually Mycobacterium tuberculosis in humans. Tuberculosis usually attacks
the lungs but can also affect other parts of the body. It is spread through the air when people who
have the disease cough, sneeze, or spit. Most infections in humans result in an asymptomatic,
latent infection, and about one in ten latent infections eventually progresses to active disease,
which, if left untreated, kills more than 50% of its victims.

II. Incubation period

 2± 10 weeks
 From the first entry until the appearance of the first signs & symptoms

III. Etiology
 overcrowded homes
 Malnutrition
 Deficiencies in Vitamin A, D, C
 Inadequate levels of immunity
 Alcoholism & smoking

IV. Risk Factors

 Close contact with someone who has active TB
 Immunocompromised status
 Preexisting medical conditions
 Living in overcrowded or substandard housing
 Significant reaction to tuberculin skin test

V. Clinical Manifestations
1.Primary Infection
 Change of behavior from normal tolistlessness
 Easy fatigability
 Alertness to apathy
 From normal activity to irritability
 Fleeting infection of respiratory/GIT associated w/ fever 
 Crepitant rales

2. Post primary/Progressive Primary Tuberculosis

 Visibly ill due to fever 
 Cough gradually becomes distressing
 Abnormal physical signs are easily elicited
 Breath sounds increased (audible crepitant rales)
 Hemoptysis is rare
 3. Chronic Pulmonary Tuberculosis
a. Generalized Systemic Signs
 General malaise, anorexia, easy fatigability, apathy, irritability, indigestion, general
influenza-like symptoms
 Physical signs are meager 
- tachycardia, low BP, dyspnea, cyanosis
 Afternoon fever  (38°C ± 39°C)
 Night sweat
 Loss of weight
 Malaise

b. Pulmonary Signs & Symptoms

 Insidious onset of cough with mucopurulent sputum
 Fine crepitant rales over apical areas
 Hemoptysis & chest pain
 Pleural pain
 Dyspnea

VI. Pathophysiology
(Book-Based)

Predisposing Factors: Precipitating Factors:

-Age -Occupation

-Immunosupressed persons -Smoking

-Systemic infections -Alcoholism

-DM

-End stage of renal disease

-HIV or AIDS

Exposure or inhalation of infected aerosol through droplet nuclei

(Exposure to infected clients by coughing, sneezing, talking)

Tubercle bacilli invasion in the apices of the lungs or near the pleurae of lower lobes

Bronchopneumonia develops in the lung tissue

 (Phagocytosed tubercle bacilli are ingested by macrophages)
-bacterial cell wall binds with macrophages
-arrest of a phagosome which results to bacilli replication

Necrotic Degeneration occurs

(production of cavities filled with cheese-like
mass of tubercle bacilli, dead WBCs, necrotic lung tissue)

drainage of necrotic materials into the

tracheobronchial tree
(eruption of coughing, formation of lesions)

PRIMARY INFECTION

Lesions may calcify (Ghon’s Complex)

And form scars and may heal over a period of time

Tubercle bacilli immunity develops (2-6weeks after infection)

(maintains in the body as long as living bacilli remains in the body)

Acquired immunity leads to further growth of bacilli and development of

ACTIVE INFECTION

SIGNS AND SYMPTOMS

Pulmonary symptoms

-dyspnea

-non-productive or productive cough

-hemoptysis

-chest pain
 -crackles may be present on auscultation

General symptoms

-fatigue

-weight loss

-anorexia

-low grade fever with sweats

SECONDARY INFECTION

Severe occurrence of lesions in the lungs

Cavitation in the lungs occur

Active infection is spread throughout the body systems

(infiltration of tubercle bacilli in other organs)

-TB of the bones

-Pott’s disease

-Renal TB

Severe occurrence of client becomes clinically ill

Bad prognosis

DEATH

VII. Diagnostic Examinations

1. Chest x-ray
2. Sputum, smear, & culture
 Finding the acid-fast bacilli in the sputum obtained by coughing & expectoration
 Culture are helpful to determine bacterial susceptibility to anti-TB drugs
 Purulent material should be cultured
3. Tuberculin skin test
 Tubercle bacillus & purified protein derivative
 Inject (Intradermal) at the inner forearm 4inches below the elbow
 Result : 48 ± 72 hours after injection
 Measure diameter of indurations in mm
Interpretation of results
 0 ± 4 mm : not significant
 > 5mm : Significant to those who are at risk: due to cross reaction to other mycobacterium
infections
: due to incompletely developed sensitivity
 >10 mm : significant to those who have normal/mildly impaired immunity: positive
reaction

VIII. Treatment
1.Prophylaxis
a.BCG (Bacilli Calmette Guerin)
 simplest, safest, most economical, & most effective measure of prevention
 Administered during neonatal period &repeated before primary school
 Given at a dose of 0.05 ± 0.1 ml intradermally over the deltoid muscle

b. Primary Chemoprophylaxis
 Administration of Isoniazid (INH) to uninfected subjects
 Administer INH instituted 8 wks after BCG vaccination in groups with high risk
infection
 Recommended daily : 5 mg/kg of body weight given in single dose

c. Secondary Chemoprophylaxis
 Progression of primary lesions can be prevented with INH with a daily dose of 5 ± 10
mg/kg of bodyweight
 Administered to patients with:
 Measles
 Pertusis
 Influenza
 Intake of steroids & immunosuppressive
 After surgery under general anesthesia

2. Specific chemotherapy
a.Isoniazid (INH) - oral 
 Duration: at least 1 yr 
 For curative purposes, should be combined with another drug to delay drug resistance
 Adverse reaction: cephalopathy hepatitis

b. Rifampicin (RMP) - oral 

 Duration:  6 months
 Has anti-mycobacterial activity & most effective anti-TB drug discovery of INH
  Adverse reaction: hypersensitivity & hepatotoxicity

c. Ethambutol (EMB) - oral 

 Duration:  3 months for initial treatment
 Dosage should be adjusted in patients w/decreased renal function
 Adverse reaction: retinal degeneration

d. Streptomycin (SM) - IM 

 Duration:  3 months - in most cases
 Skin test before administration
 Should not be given as the sole agent because bacterial resistance develops more rapidly
 Adverse reaction: nephrotoxicity, vertigo, ataxia

e. Morphozinamide Hydrochloride (MZA) - oral 

 Duration:  with INH
 Pyrazinamide derivative
 Very effective anti-TB drug especially in caseous forms of TB
 Adverse reaction: Hepatitis

f. Para-amino salicylic Acid (PAS) - oral 

 Duration:  with INH
 Weakest among anti-TB drug
 Delays the emergence of resistant strains of tubercle bacilli
 Adverse reaction: gastric irritation

IX. Surgical Management

 Pneumonectomy
 Indications: bronchiectasis, tuberculoma, cavitary lesions, pulmonary cirrhosis,
atelectasis
 Contraindication: active parenchymal lesions & endobronchial tuberculosis

X. Nursing Management
 Maintain respiratory isolation until patient responds to treatment or no longer contagious
 Administer medicines as ordered
 Check sputum always for blood
 Encourage questions, conversation, to air their feelings
 Teach or educate patient
 Encourage to stop smoking
 Teach patient to cough/sneeze into tissue paper & dispose secretions properly
 Advise patient to have plenty of rest & eat balance diet
 Be alert on signs of drug reaction