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    • #3619
      Abraham ItodoAbraham Itodo

      TOPIC: PULMONARY TUBERCULOSIS.

      INTRODUCTION.

      Tuberculosis is a leading infectious cause of morbidity and morbidity in adult’s worldwide, killing about 1.7millon people in 2016, most of them in low-middle-income countries. HIV/AIDS is the most important factor predisposing to TB infection and mortality in parts of the world where both infections are prevalent.
      According to the Centers for Disease Control and Prevention (CDC) TB is one of the word’s deadliest diseases, with approximately 1.3million related deaths occurring cause of death among people who have HIV.
      In 2016 Doctors attributed 528deaths to TB in the US , an increase from the 470 deaths reported in 2015.The CDC estimate that up to 1.3million people in the US may have latent TB and that around 1 in 10 of these individuals will develop active TB.
      What is pulmonary tuberculosis?
      Pulmonary tuberculosis (PTB) is a chronic respiratory disease common among crowded and poorly ventilated areas.
      • An acute or chronic infection caused by Mycobacterium tuberculosis, tuberculosis is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation.
      • Tuberculosis is an infectious disease that primarily affects the lung parenchyma.
      • It also may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes.
      • The primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light.
      • Pulmonary tuberculosis is a chronic, progressive mycobacterial infection, often with a period of latency following initial infection.
      • PTB most commonly affects the lungs Symptoms includes a bad cough that lasts for at least 3weeks, Chest pain, coughing up blood or phlegm from the lungs and breathlessness.

      Epidemiology.
      About one third of the world’s population is infected with tuberculosis. Every year three million people die from tuberculosis, mostly in developing countries where it kills one in five adults. The
      World Health Organization (WHO) had predicted a global tuberculosis epidemic, causing 30 million deaths during the 1990s.The number of new pulmonary tuberculosis cases world-wide is expected to increase from around seven million in 1990 to over ten million by 2000. Nearly 75% of PTB cases in the developing countries belong to the economically active group of the population. It also causes unprecedented levels of infection and deaths among women and girls. This makes TB the leading cause of death among women of reproductive age group.
      The National Tuberculosis and Leprosy Control Program (NTLCP) estimates that the annual number of new cases amount to about 90000 of which about 45% are open pulmonary tuberculosis cases. Some of the main reasons suggested for the widespread of pulmonary tuberculosis are HIV infection, neglect of tuberculosis program, rapidly growing slums with crowded living conditions, lack of access to modern health care and deficient medical services.
      Etiology.
      Pulmonary tuberculosis is caused by a type of the bacterium called mycobacterium tuberculosis. Occasionally it can be caused by mycobacterium bovis and mycobacterium African but of much less magnitude.
      Types of Pulmonary Tuberculosis.
      A TB infection doesn’t always mean you will get sick.
      There are two forms of the disease.
      • Latent TB. You have the germs in your body, but your immune system keeps them from spreading. You don’t have any symptoms, and you’re not contagious. But the infection is still alive and can one day become active. If you’re at high risk for re-activation — for instance, if you have HIV, you had an infection in the past 2 years, your chest X-ray is unusual, or your immune system is weakened — your doctor will give you medications to prevent active TB.
      • Active TB. The germs multiply and make you sick. You can spread the disease to others. Ninety percent of active cases in adults come from a latent TB infection.
      • Active TB is an illness in which the TB bacteria are rapidly multiplying and invading different organs of the body. The typical symptoms of active TB variably include cough, phlegm, chest pain, weakness, weight loss, fever, chills and sweating at night. A person with active pulmonary TB disease may spread TB to others by airborne transmission of infectious particles coughed into the air.
      • If you are diagnosed with an active TB disease, be prepared to give a careful, detailed history of every person with whom you have had contact. Since the active form may be contagious, these people will need to be tested, as well.
      • A latent or active TB infection can also be drug-resistant, meaning certain medications don’t work against the bacteria.
      Other categories of pulmonary tuberculosis.
      A. Primary tuberculosis.
      B. Secondary tuberculosis.
      A. Primary tuberculosis.
      The infection of an individual who has not been previously infected or immunized is called primary tuberculosis or Ghon’s complex or childhood tuberculosis.
      Lessons forming after the infection is peripheral and accompanied by hilar which may not be detectable on chest radiography.
      B. Secondary tuberculosis.
      The infection that individual who has been previously infected or sensitized is called secondary tuberculosis or post primary or chronic tuberculosis.

      Pulmonary tuberculosis risk factors.
      You could be more likely to get TB if:
      • A friend, co-worker, or family member has active TB.
      • You live in or have traveled to an area where TB is common, like Russia, Africa, Eastern Europe, Asia, Latin America, and the Caribbean.
      • You’re part of a group in which TB is more likely to spread, or you work or live with someone who is. This includes homeless people, people who have HIV, people in jail or prison, and people who inject drugs into their veins.
      • You work or live in a hospital or nursing home.
      • You’re a health care worker for patients at high risk of TB.
      • You’re a smoker.

      Signs and symptoms
      Classic clinical features associated with active pulmonary TB are as follows (elderly individuals with TB may not display typical signs and symptoms):
      • Cough
      • Weight loss/anorexia
      • Fever
      • Night sweats
      • Hemoptysis
      • Chest pain (can also result from tuberculous acute pericarditis).
      • Fatigue.
      According to Belayneh Tadesse MD,et al (2019);
      Clinical features of pulmonary tuberculosis includes:

       Persistent cough for more than three weeks
       Sputum production which may or may not be blood stained.
       Weight loss.
       Chest pain.
       Shortness of breath
       Intermittent fever, night sweats.
       Loss of appetite, fatigue and malaise
       History of contact with a smear positive PTB cases.

      Pathophysiology.
      Infection with mycobacterial tuberculosis results most commonly through exposure of the lungs or mucous membranes to infected aerosols. Droplets in these aerosols are 1-5 μm in diameter; in a person with active pulmonary TB, a single cough can generate 3000 infective droplets, with as few as 10 bacilli needed to initiate infection.
      When inhaled, droplet nuclei are deposited within the terminal airspaces of the lung. The organisms grow for 2-12 weeks, until they reach 1000-10,000 in number, which is sufficient to elicit a cellular immune response that can be detected by a reaction to the tuberculin skin test.
      Mycobacteria are highly antigenic, and they promote a vigorous, nonspecific immune response. Their antigenicity is due to multiple cell wall constituents, including glycoproteins, phospholipids, and wax D, which activate Langerhans cells, lymphocytes, and polymorphonuclear leukocytes
      When a person is infected with M tuberculosis, the infection can take 1 of a variety of paths, most of which do not lead to actual TB. The infection may be cleared by the host immune system or suppressed into an inactive form called latent tuberculosis infection (LTBI), with resistant hosts controlling mycobacterial growth at distant foci before the development of active disease. Patients with LTBI cannot spread TB.
      The lungs are the most common site for the development of TB; 85% of patients with TB present with pulmonary complaints. Extrapulmonary TB can occur as part of a primary or late, generalized infection. An extrapulmonary location may also serve as a reactivation site; extrapulmonary reactivation may coexist with pulmonary reactivation.
      The most common sites of extrapulmonary disease are as follows (the pathology of these lesions is similar to that of pulmonary lesions):
      • Mediastinal, retroperitoneal, and cervical (scrofula) lymph nodes – The most common site of tuberculous lymphadenitis (scrofula) is in the neck, along the sternocleidomastoid muscle; it is usually unilateral and causes little or no pain; advanced cases of tuberculous lymphadenitis may suppurate and form a draining sinus.
      • Vertebral bodies
      • Adrenals
      • Meninges
      • GI tract
      Infected end organs typically have high regional oxygen tension (as in the kidneys, bones, meninges, eyes, and choroids, and in the apices of the lungs). The principal cause of tissue destruction from M tuberculosis infection is related to the organism’s ability to incite intense host immune reactions to antigenic cell wall proteins.
      Uveitis caused by TB is the local inflammatory manifestation of a previously acquired primary systemic tubercular infection. There is some debate with regard to whether molecular mimicry, as well as a nonspecific response to noninfectious tubercular antigens, provides a mechanism for active ocular inflammation in the absence of bacterial replication.

      According to nurseslab.com
      Pathophysiology of PTB.
      Tuberculosis is a highly infectious, airborne disease.
      • Inhalation. Tuberculosis begins when a susceptible person inhales mycobacteria and becomes infected.
      • Transmission. The bacteria are transmitted through the airways to the alveoli, and are also transported via lymph system and bloodstream to other parts of the body.
      • Defense. The body’s immune system responds by initiating an inflammatory reaction and phagocytes engulf many of the bacteria, and TB-specific lymphocytes lyse the bacilli and normal tissue.
      • Protection. Granulomas new tissue masses of live and dead bacilli, ate surrounded by macrophages, which form a protective wall.
      • Ghon’s tubercle. They are then transformed to a fibrous tissue mass, the central portion of which is called a Ghon’s tubercle.
      • Scarring. The bacteria and macrophages turns into a cheesy mass that may become calcified and form a collagenous scar.
      • Dormancy. At this point, the bacteria become dormant, and there is no further progression of active disease.
      • Activation. After initial exposure and infection, active disease may develop because of a compromised or inadequate immune system response.

      Complication of pulmonary Tuberculosis.
      Tuberculosis infection can cause complications such as:
      • Joint damage
      • Lung damage
      • Infection or damage of your bones, spinal cord, brain, or lymph nodes
      • Liver or kidney problems.
      • Inflammation of the tissues around your heart.
      According to Nurseslab.com complication of PTB.
      If left untreated or mistreated, pulmonary tuberculosis may lead to:
      • Respiratory failure. Respiratory failure is one of the most common complication of pulmonary tuberculosis.
      • Pneumothorax. Pneumothorax becomes a complication when tuberculosis is not treated properly.
      • Pneumonia. One of the most fatal complications of tuberculosis is pneumonia as it could cause infection all over the lungs.

       

      Diagnosis/laboratory investigations.

      Screening methods for TB include the following:
      • Mantoux tuberculin skin test with purified protein derivative (PPD) for active or latent infection (primary method)
      • In vitro blood test based on interferon gamma release assay (IGRA) with antigens specific for Mycobacterium tuberculosis for latent infection.
      • Obtain a chest radiograph to evaluate for possible associated pulmonary findings.
      Obtain the following laboratory tests for patients with suspected TB:
      • Acid-fast bacilli (AFB) smear and culture using sputum obtained from the patient: Absence of a positive smear result does not exclude active TB infection; AFB culture is the most specific test for TB
      • HIV serology in all patients with TB and unknown HIV status: Individuals infected with HIV are at increased risk for TB.
      Other diagnostic testing may warrant consideration, including the following:
      • Specific enzyme-linked immunospot (ELISpot)
      • Nucleic acid amplification tests.
      • Blood culture.

      According to nurseslab.com assessment and diagnostic findings.
      To diagnose tuberculosis, the following tests could be performed:
      • Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the disease.
      • Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid): Positive for acid-fast bacilli (AFB).
      • Skin tests (purified protein derivative [PPD] or Old tuberculin [OT] administered by intradermal injection [Mantoux]): A positive reaction (area of induration 10 mm or greater, occurring 48–72hours after interdermal injection of the antigen) indicates past infection and the presence of antibodies but is not necessarily indicative of active disease. Factors associated with a decreased response to tuberculin include underlying viral or bacterial infection, malnutrition, lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and conscious or unconscious bias. A significant reaction in a patient who is clinically ill means that active TB cannot be dismissed as a diagnostic possibility. A significant reaction in healthy persons usually signifies dormant TB or an infection caused by a different mycobacterium.
      • Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV.
      • Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-lung field, calcium deposits of healed primary lesions, or fluid of an effusion. Changes indicating more advanced TB may include cavitation, scar tissue/fibrotic areas.
      • CT or MRI scan: Determines degree of lung damage and may confirm a difficult diagnosis.
      • Bronchoscopy: Shows inflammation and altered lung tissue. May also be performed to obtain sputum if patient is unable to produce an adequate specimen.
      • Histologic or tissue cultures (including gastric washings; urine and cerebrospinal fluid [CSF]; skin biopsy): Positive for Myco¬bacterium tuberculosis and may indicate extrapulmonary involvement.
      • Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells indicating necrosis.
      • Electrolytes: May be abnormal depending on the location and severity of infection; e.g., hyponatremia caused by abnormal water retention may be found in extensive chronic pulmonary TB.
      • ABGs: May be abnormal depending on location, severity, and residual damage to the lungs.
      • Pulmonary function studies: Decreased vital capacity, increased dead space, increased ratio of residual air to total lung capacity, and decreased oxygen saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue, and pleural disease (extensive chronic pulmonary TB).

      MANAGEMENT.
      Medical management.
      Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12 months.
      • First line treatment. First-line agents for the treatment of tuberculosis are isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide.
      • Active TB. For most adults with active TB, the recommended dosing includes the administration of all four drugs daily for 2 months, followed by 4 months of INH and RIF.
      • Latent TB. Latent TB is usually treated daily for 9 months.
      • Treatment guidelines. Recommended treatment guidelines for newly diagnosed cases of pulmonary TB have two parts: an initial treatment phase and a continuation phase.
      • Initial phase. The initial phase consists of a multiple-medication regimen of INH, rifampin, pyrazinamide, and ethambutol and lasts for 8 weeks.
      • Continuation phase. The continuation phase of treatment include INH and rifampin or INH and rifapentine, and lasts for an additional 4 or 7 months.
      • Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for 6 to 12 months.
      • DOT. Directly observed therapy may be selected, wherein an assigned caregiver directly observes the administration of the drug.
      Pharmacologic Therapy.
      The first line antituberculosis medications include:•
      • Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for neuritis, and has side effects of peripheral neuritis, hepatic enzyme elevation, hepatitis, and hypersensitivity.
      • Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the urine and other body secretions into orange or red, and has common side effects of hepatitis, febrile reaction, purpura, nausea, and vomiting.
      • Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid in the blood and has common side effects of hyperuricemia, hepatotoxicity, skin rash, arthralgia, and GI distress.
      • Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that should be used with caution with renal disease, and has common side effects of optic neuritis and skin rash.
      Nursing Management.
      Nursing management includes the following:
      Nursing Assessment.
      The nurse may assess the following:
      • Complete history. Past and present medical history is assessed as well as both of the parents’ histories.
      • Physical examination. A TB patient loses weight dramatically and may show the loss in physical appearance.

      Nursing Diagnosis.
      Based on the assessment data, the major nursing diagnoses for the patient include:
      • Risk for infection related to inadequate primary defenses and lowered resistance.
      • Ineffective airway clearance related to thick, viscous, or bloody secretions.
      • Risk for impaired gas exchange related to decrease in effective lung surface.
      • Activity intolerance related to imbalance between oxygen supply and demand.
      • Imbalanced nutrition: less than body requirements related to inability to ingest adequate nutrients.

      Nursing Care Planning & Goals.
      The major goals for the patient include:
      • Promote airway clearance.
      • Adhere to treatment regimen.
      • Promote activity and adequate nutrition.
      • Prevent spread of tuberculosis infection.
      Nursing Interventions.
      Nursing interventions for the patient include:
      • Promoting airway clearance. The nurse instructs the patient about correct positioning to facilitate drainage and to increase fluid intake to promote systemic hydration.
      • Adherence to the treatment regimen. The nurse should teach the patient that TB is a communicable disease and taking medications is the most effective means of preventing transmission.
      • Promoting activity and adequate nutrition. The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength and a nutritional plan that allows for small, frequent meals.
      • Preventing spreading of tuberculosis infection. The nurse carefully instructs the patient about important hygienic measures including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and handwashing.
      • Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use of a private room with negative pressure in relation to surrounding areas and a minimum of six air changes per hour.
      • Disposal. Place a covered trash can nearby or tape a lined bag to the side of the bed to dispose of used tissues.
      • Monitor adverse effects. Be alert for adverse effects of medications.
      • Discharge and home care guidelines.
      Before the discharge, the nurse should instruct
      the patient to:
      • Disposal of secretions. Cough and sneeze into tissues and to dispose of all secretions in a separate trash can.
      • Isolation. Wear a mask when going outside of the room.
      • Activity and nutrition. Remind the patient to take a lot of rest and to eat balanced meals to aid recovery.
      • Adverse effects. Advise the patient to watch out for adverse effects of medications and to report them to the physician immediately.

      Aims of Anti-TB drug treatment
      • The principal aims of anti-TB treatment are the following:
      • To cure the patient of PTB,
      • To prevent death from active PTB or its late effects,
      • To prevent TB relapse, and
      • To decrease and prevent PTB transmission to others.
      • In the majority of cases, treatment of PTB is successfully achieved by means of adequate
      • chemotherapy alone. Adequate and successful chemotherapy relies on the choice of:
      • Appropriate combination of drugs,
      • Correct dosage, and
      • Regular intake for sufficient period.
      • Chemotherapy is considered to be adequate if it fulfils the following.
      • When it cures patients;
      • When it rapidly and substantially reduces the number of actively multiplying bacteria,
      • and When it prevents the development of resistance to the drugs.
      • Pulmonary TB treatment regimens according to the TLCT and WHO recommendations are
      • combinations of drugs. A portion of these drugs would help to weaken and stop multiplication of
      • the bacteria but may not kill them. These are called bacteriostatic drugs .The other drug groups
      • are called bactericidal which have the capacity of destroying the bacteria. Bombardment of the
      • bacteria with these drug combinations would help to eliminate the bacteria and reduce
      • development of drug resistance if administrated and taken in appropriate manner.

      Phases of Chemotherapy
      There are two phases of treatment:
      • Intensive (initial) phase: the first two or three months of treatment.
      • Continuation phase: the remaining duration of treatment.
      Standard Drug Regimens
      • There are two recommended standard TB drug regimens:
      • Directly Observed Treatment Short Course (DOTS), which is for eight months; in DOTS the patients are given the drugs under observation by the health worker for the first two months.
      • This direct supervision by health worker ensures patient adherence to the treatment and is given for short period of time.
      • However, in DOTS modality of TB treatment services should be available as close to home as possible.
      • Long course chemotherapy (LCC), which is for 12 months.
      Preventive Measures.
       Proper detection and treatment,
       BCG (Bacillus Calmete Guerin) vaccination,
       Preventive chemotherapy to high-risk groups,
       Improving housing conditions (proper ventilation and sunlight), and
       Health education.
      • Explain the causative agent.
      • Explain how the disease is spread.
      • Give clear instructions on the need for regular and uninterrupted treatment,
      • Explain the importance of follow up.
      • Explain the preventive and control measures.
      • Encourage patients to undergo volunteer HIV counseling and test.
      Control Measures
       Passive and active case detection,
       Examination of contacts,
       Provision of chemotherapy,
       Absentee retrieval,
       Concurrent disinfection,
       Reporting of cases, and
       Surveillance and monitoring.

      Reference.
      1. Msdmanuals.com (MSD manual professional version)
      2..emedicine.medscape.com
      3.medicalnewstoday.com.
      4.Nurseslab.com.

      Written by Itodo Abraham A.(RN, DDM, PDSSM).

       

       

    • #3624
      Solutions JamesSolutions James

      You write pretty well, and that you referenced it is so cool.

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