Pulmonary Tuberculosis

 Is a preventable disease that is curable if detected early, before the bacilli

disseminate and complications occur.
 Is an infectious disease that primarily affects the lung parenchyma.

I. Causative Agent

 Myobacterium Tuberculosis (tubercle bacillus)

 It is a slow-growing aerobic bacterium that divides every 16 to 20 hours
 This is extremely slow compared to other bacteria that have division time
measured in minutes.

• In contrast, one of the fastest growing bacteria is a strain of E. coli that can
divide roughly every 20 minutes.
 As MTB only has one phospholipid outer membrane, it is classified as Gram-
positive bacteria.
 However, if a Gram stain is performed, MTB either stains very weakly Gram-
positive, or does not retain dye, due to the high lipid content of its cell wall.
 Withstand weak disinfectants and can survive in a dry state for weeks.

• Normally, the bacteria can only grow within a host organism, so in vitro
culture of M. tuberculosis took a long time to develop, but is now a routine
laboratory procedure

The well-developed cell wall contains a considerable amount of a fatty acid,

mycolic acid, covalently attached to the underlying peptidoglycan-bound polysaccharide
arabinogalactan, providing an extraordinary lipid barrier. This barrier is responsible for
many of the medically challenging physiological characteristics of tuberculosis, including
resistance to antibiotics and host defense mechanisms.

II. The disease and its Pathophysiology

This type of tuberculosis affects the respiratory system, primarily the lungs. Tiny droplets
carrying the bacteria are ingested through the nose or mouth, driven to the lungs and
from there on tuberculosis can spread to the liver, kidneys and other organs.

Most people who develop symptoms of a TB infection first became infected in the past.
However, in some cases, the disease may become active within weeks after the primary
infection.

The following people are at higher risk for active TB:

• Elderly
• Infants
• People with weakened immune systems, for example due to AIDS,
chemotherapy, or antirejection medicines given after an organ transplant

The risk of contracting TB increases if:

 • The person is in frequent contact with people who have the disease;
• Have poor nutrition;
• Live in crowded or unsanitary living conditions.

The following factors may increase the rate of TB infection in a population:

• Increase in HIV infections

• Increase in number of homeless people (poor environment and nutrition)
• The appearance of drug-resistant strains of TB

 Pathophysiology of Pulmonary Tuberculosis

• Pulmonary TB is caused by M. tuberculosis which is a rod-shaped bacteria with a
waxy capsule.
• It is non-motile (requires external forces, such as coughing for example, to move
from place to place), does not form spores, and is aerobic (grows best in an
oxygen rich environment).
• The most common transmission is human to human although there have been
incidences of animal to human transmission through unpasteurized cow’s milk.
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.
Examples of this include:
o coughing
o sneezing
o talking
o singing
o Playing a musical instrument, etc.
• These particles remain suspended in the air and, once inhaled by a susceptible
person, they can cause infection deep inside the lung.
• All segments of the lungs are susceptible to infection but there is disagreement in
the literature as to which areas are most commonly infected.
• 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.
• 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.
• Upon reactivation of the bacteria, a secondary tuberculosis infection can develop.
• 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.
• Secondary TB is not self-limiting, does not resolve on it’s own with the help of the
body’s immune system, and is more problematic in terms of causing further
complications.

These complications may include:

 • 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)

The end result (without treatment) is often massive destruction of the lungs due to
liquification and cavitation of lung tissue.

 PATTERNS OF INFECTION

There are two major patterns of disease with TB:

1. Primary tuberculosis
 Seen as an initial infection, usually in children.
 The initial focus of infection is a small subpleural granuloma accompanied by
granulomatous hilar lymph node infection.
 Together, these make up the Ghon complex. In nearly all cases, these
granulomas resolve and there is no further spread of the infection.
2. Secondary tuberculosis
 Seen mostly in adults as a reactivation of previous infection (or reinfection),
particularly when health status declines.
 The granulomatous inflammation is much more florid and widespread.
 Typically, the upper lung lobes are most affected, and cavitation can occur.

III. PREVENTION OF THE DISEASE

TB is a preventable disease, even in those who have been exposed to an infected

person. Skin testing (PPD) is a screening test for TB used in high risk populations or in
those who may have been exposed to TB (such as all health care workers).

A positive test indicates prior TB exposure and indications for preventive therapy should
be discussed with your doctor. Individuals exposed to tuberculosis should be skin tested
immediately and the skin test repeated at a later date, if the initial test is negative.

Prompt treatment is extremely important in controlling the spread of tuberculosis for

thosewho have already progressed to active TB disease.

 TEST AND EXAMS

Examination may show:

• Clubbing of the fingers or toes (in people with advanced disease)

• Enlarged or tender lymph nodes in the neck or other areas
• Fluid around a lung
• Unusual breath sounds (crackles)
Tests may include:

• Biopsy of the affected tissue (rare)

• Bronchoscopy
• Chest CT scan
• Chest x-ray
• Interferon-gamma blood test such as the QFT-Gold test to test for TB infection
• Sputum examination and cultures
• Thoracentesis
• Tuberculin skin test

IV. TREATMENT

• Treatment for TB uses antibiotics to kill the bacteria.

• Treatments are more difficult than the short courses of antibiotics used to cure
most bacterial infections as long periods of treatment (around 6 to 12 months)
are needed to entirely eliminate mycobacteria from the body.
• Latent TB treatment usually uses a single antibiotic, while active TB disease is
best treated with combinations of several antibiotics, to reduce the risk of the
bacteria developing antibiotic resistance.
• Drug resistant tuberculosis is transmitted in the same way as regular TB

The goal of treatment is to cure the infection with drugs that fight the TB bacteria.
Treatment of active pulmonary TB will always involve a combination of many drugs. All
of the drugs are continued until lab tests show which medicines work best.

The most commonly used drugs include:

• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol

Other drugs that may be used to treat TB include:

• Amikacin
• Ethionamide
• Moxifloxacin
• Para-aminosalicylic acid
• Streptomycin

The infected person needs to take many different pills at different times of the day for 1
year or longer. It is very important that he take the pills the way his health care provider
instructed.

When people do not take their tuberculosis medications as recommended, the infection
becomes much more difficult to treat. The TB bacteria may become resistant to
treatment, and sometimes, the drugs no longer help treat the infection.
When there is a concern that a patient may not take all the medication as directed, a
health care provider may need to watch the person take the prescribed drugs. This is
called directly observed therapy. In this case, drugs may be given 2 or 3 times per week,
as prescribed by a doctor.

The patient may need to be admitted to a hospital for 2 - 4 weeks to avoid spreading the
disease to others until he is no longer contagious.

V. HEALTH CARE MANAGEMENT

Some common diagnoses and interventions of community health workers for this
condition would be:

 Risk for infection

• Monitor sputum for changes indicating infection

• Monitor vital signs
• Teach patient and family the purpose and techniques for infection control such as
hand washing, patient covering mouth when coughs, maintaining isolation if
necessary
• Teach patient the purpose, importance and how to take medications as prescribed
consistently over the long term therapy

 Deficient knowledge

• Determine who will be the learner, patient or family

• Assess ability to learn
• Identify any existing misconceptions about the material to learn
• Assist the learner to integrate the information into daily life
• Give clear thorough explanations and demonstrations

 Noncompliance

• Determine if there has been past noncompliance and the reasons

• Ask to see prescription drugs periodically and count the remaining pills
• If economics are a reason for noncompliance, explore community resources
• Increase the amount of supervision provided, follow up visits, phone calls, etc.

 Ineffective therapeutic regimen management

• Assess prior efforts to follow regimen

• Assess patient's perceptions of their health problem
• Assess other factors that may affect success in a negative way
• Inform patient of the benefits of conforming with the regimen
• Concentrate on the behaviors that will make the most difference to the therapeutic
effect
• Include family, support system in teachings and explanations
• Instruct patient on the importance of ordering refills of medications several days
ahead of running out.

 Activity intolerance

• Assess patient's level of mobility

• Observe and document response to activity
• Assess emotional response to change in physical status
• Anticipate patient's needs to accommodate
• Teach energy conservation techniques
• Refer to community resources as needed

 Ineffective airway clearance

• Auscultate lungs for wheezing, decreased breath sounds, coarse sounds

• Use universal precautions if secretions are purulent even before culture reports
• Assess cough for effectiveness and productivity
• Institute appropriate isolation precautions if cultures are positive
• Administer medications, noting effectiveness and side effects
• Teach effective deep breathing and coughing techniques

 Ineffective health maintenance

• Assess patient's knowledge of health maintenance behaviors

• Assess to what degree environmental, social, intrafamilial disruptions, or changes
have correlated with poor health behaviors
• Determine patient's motives for failing to report symptoms reflecting changes in
health status
• Assess whether economic problems present a barrier to maintaining health
behaviors
• Provide patient with a means to contact health care providers
• Involve family and friends in health planning conferences