PULMONARY TUBERCULOSIS

Tuberculosis (TB) 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 Mycobacterium tuberculosis, is an acid-fast aerobic rod that
grows slowly and is sensitive to heat and ultraviolet light.
Mycobacterium avium and Mycobacterium bovis have been rarely associated with the
development of a TB infection.

PATHOPHYSIOLOGY
TB begins when a susceptible person inhales mycobacteria & become infected. The bacteria
are transmitted through the airways to the alveoli, where they are deposited and begin to
multiply. The bacilli are transported via the lymph system and bloodstream to other parts of
the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes). The
bodys immune system respond by initiating an inflammatory reaction. Phagocytes
(neutrophils and macrophage) engulf many of the bacteria, and TB- specific lymphocytes lyse
(destroy) the bacilli and normal tissue. This tissue reaction results in the accumulation of
exudates in the alveoli, causing bronchopneumonia.The initial infection usually occurs 2 to 10
weeks after exposure.
Granulomas, new tissue masses of dead and live bacilli, are surrounded by
macrophages, which form a protective wall . They are then transformed to fibrous tissue
mass, the central portion of which is called Ghon tubercle. The material (bacteria and
macrophages) becomes necrotic, forming a cheesy mass. This mass may become calcified
and form a collagenous scar. At this point, the bacteria become dormant; and there is no
further progression of active disease.
After initial exposure and infection, active disease may develop because of a
compromised or inadequate immune system response. Active disease also may occur with
reinfection and activation and activation of dormant bacteria. In this case, the Ghon tubercle
ulcerates, releasing the cheesy material into the bronchi. The bacteria then become airborne,
resulting in further spread of the disease. Then the ulcerated tubercle heals and forms scar
tissue. This causes the infected lung to become more inflamed, resulting in further
development of bronchopneumonia and tubercle formation.
Unless the process is arrested, it spreads slowly downward to the hilum of the lungs
and later expands to adjacent lobes. The process may be prolonged and is characterized by
long remissions when the disease is arrested, followed by periods of renewed activity.
Approximately 10% of people who are initially infected develop active disease. Some people
develop reactivation TB (also called adult-type TB). This type of TB results from a breakdown
of the host defenses. It most commonly occurs in the lungs , usually in the apical or posterior
segments of the upper lobes or the superior segments of the lower lobes.
TB spreads from person to person by airborne transmission. An infected person
releases droplet nuclei (usually particles 1 to 5 m in diameter) through talking, coughing,
sneezing, laughing or singing. Larger droplets settle; smaller droplets remain suspended in
the air and are inhaled by a susceptible person.

PATHOPHYSIOLOGY OF TUBERCULOSIS

CLINICAL MANIFESTATIONS

Low-grade afternoon fever

Night sweating
Loss of appetite
Weight loss
Easy fatigability- due to increased oxygen demand
Productive dry cough
Hemoptysis

ASSESSMENTS AND DIAGNOSTIC FINDINGS

Diagnostic tests
A . Sputum Exam or Acid-fast bacilli (AFB)/ Sputum microscopy
confirmatory test of TB
Early morning sputum about 3-5 cc
Maintain NPO before collecting sputum
Give oral care after procedure
Label and send immediately to laboratory
If the time of the collection of the sputum is unknown, discard

B. Chest X-ray
To determine the clinical activity of TB, whether it is inactive(in control) or active
(ongoing).
To determine the extent of the lesion:
a. Minimal
-very small
b. Moderately advance
-lesion is <4cm
c. Far advance
-lesion is >4cm

C. Tuberculin Test /Mantoux Test

The purpose is to determine the history of exposure to tuberculosis.The test result is
read 48-72 hours after injection.
Interpretation:

0-4 mm induration
-not significant
5 mm or more
- significant in individuals who are considered at risk; positive for patients who
are
HIV
positive
or
have HIV risk factors and are unknown HIV status, those who are close contact
with
an
active
case,
and those who have chest x-ray results consistent with TB.
10 mm or greater
- significant in individuals who have normal or mildly impaired immunity

MANAGEMENT
Medical Management

Pharmacologic Management
1. Pulmonary TB is treated with chemotherapeutic agents (antituberculosis agents) for 6-12
months
2. Identify 3 types of Resistance
Primary Resistance
- resistance to one or first line antituberculosis agents in people who have not had
previous treatment.

Secondary or Acquired Drug Resistance

- resistance to one or more antituberculosis agents in patients undergoing therapy.
Multidrug Resistance
-resistance to 2 agents, Isoniazid (INH) and rifampicin

First line anti-TB drug

R- Rifampicin
I- Isoniazid
P- Pyrazinamide
E- EthambutoL

Combined Medications
1. INH and Rifampin (Rifamate)
2. INH, Rifampin, Pyrazinamide (Rifater)

Second line Anti-TB agent

Other Medications
1. Capreomycin
1. Amonoglycosides
2. Ethionamide
2. Quinolones
3. Para-aminosalicyclate sodium
3. Rifabutin
4. Cycloserine
4. Clofazimine
Phases of treatment
1. Initial Phase 8 weeks
2. Continuation Phase- lasts for additional 4-7 months

Drugs
Rifampicin

Isoniazid
Pyrazinamide
Ethambutol

Streptomycin

Side Effects
-body fluid discoloration
-hepatotoxic
-permanent discoloration of contact lenses
-peripheral neuropathy
(Give Vit. B6/ Pyridoxine)
-Hyperurecemia/ gouty arthritis
(Increase fluid intake)
-Optic Neuritis
-Blurring of vision
(Not to be given to children below 6
years old due to inability to complain of
blurring of vision)
-Damage to the 8th Cranial nerve
-Ototoxic
-Tinnitus
-Nephrotoxic

Category 1
Category 2
Category 3
Intensive Phase RIPE ( 2 mo.s)
Intensive Phase RIPE ( 3 mo.s)
Intensive Phase RIPE ( 2 mo.s)
Continuation Phase RI ( 4 mo.s)
Continuation Phase RI ( 5 mo.s)
Continuation Phase RI ( 4 mo.s)
(-)smear with extensive
Treatment failure
(-)smear PTB with minimal

Relapse
parenchymal lesions
lesions on CXR
Return after default
Extrapulmonary TB
Same meds with Category 1
Severe concominant HIV
disease

The organs of the respiratory system extend from the nose to the lungs and are divided into the upper and
lower respiratory tracts. The upper respiratory tract consists of the nose and the pharynx, or throat. The lower
respiratory tract includes the larynx, or voice box; the trachea, or windpipe, which splits into two main
branches called bronchi; tiny branches of the bronchi called bronchioles; and the lungs, a pair of saclike,
spongy organs. The nose, pharynx, larynx, trachea, bronchi, and bronchioles conduct air to and from the
lungs. The lungs interact with the circulatory system to deliver oxygen and remove carbon dioxide .

Anatomy of the Nose

The uppermost portion of the human
respiratory system, the nose is a
hollow air passage that functions in
breathing and in the sense of smell.
The nasal cavity moistens and warms
incoming air, while small hairs and
mucus filter out harmful particles and

A. Nasal Passages
The flow of air from outside of the body to the lungs begins with the nose, which is divided into the left and
right nasal passages. The nasal passages are lined with a membrane composed primarily of one layer of
flat, closely packed cells called epithelial cells. Each epithelial cell is densely fringed with thousands of
microscopic cilia, fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet cells,
specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial cells and the cilia.
Numerous tiny blood vessels called capillaries lie just under the mucous membrane, near the surface of
the nasal passages. While transporting air to the pharynx, the nasal passages play two critical roles: they
filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect
the structures in the respiratory system.
B. Pharynx
Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube about 13 cm (5 in)
long that transports air to the larynx. Like the nasal passages, the pharynx is lined with a protective
mucous membrane and ciliated cells that remove impurities from the air. In addition to serving as an air
passage, the pharynx houses the tonsils, lymphatic tissues that contain white blood cells. The white blood
cells attack any disease-causing organisms that escape the hairs, cilia, and mucus of the nasal passages
and pharynx. The tonsils are strategically located to prevent these organisms from moving further into the
body. One tonsil, called the adenoids, is found high in the rear wall of the pharynx. A pair of tonsils, the
palatine tonsils, is located at the back of the pharynx on either side of the tongue. Another pair, the lingual
tonsils, is found deep in the pharynx at the base of the tongue. In their battles with disease-causing
organisms, the tonsils sometimes become swollen with infection. When the adenoids are swollen, they
block the flow of air from the nasal passages to the pharynx, and a person must breathe through the
mouth.
C. Larynx
Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located approximately in the
middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise most of the larynx. A
protrusion in the cartilage called the Adams apple sometimes enlarges in males during puberty, creating a
prominent bulge visible on the neck.
While the primary role of the larynx is to transport air to the trachea, it also serves other functions. It plays
a primary role in producing sound; it prevents food and fluid from entering the air passage to cause
choking; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the larynx waft
airborne particles up toward the pharynx to be swallowed.
Food and fluids from the pharynx usually are prevented from entering the larynx by the epiglottis, a thin,
leaflike tissue. The stem of the leaf attaches to the front and top of the larynx. When a person is
breathing, the epiglottis is held in a vertical position, like an open trap door. When a person swallows,
however, a reflex causes the larynx and the epiglottis to move toward each other, forming a protective
seal, and food and fluids are routed to the esophagus. If a person is eating or drinking too rapidly, or
laughs while swallowing, the swallowing reflex may not work, and food or fluid can enter the larynx. Food,
fluid, or other substances in the larynx initiate a cough reflex as the body attempts to clear the larynx of
the obstruction. If the cough reflex does not work, a person can choke, a life-threatening situation. The
Heimlich maneuver is a technique used to clear a blocked larynx (see First Aid). A surgical procedure called
a tracheotomy is used to bypass the larynx and get air to the trachea in extreme cases of choking.
D. Trachea, Bronchi, Bronchioles
Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6 in) long located just
below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings
hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies
at the back of the trachea, and the ends of the C are connected by muscle tissue. The base of the
trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches
into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within
the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few
bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with
mucous membranes and ciliated cells that move mucus upward to the pharynx.

Al

Lungs
In humans the lungs occupy
a large portion of the chest
cavity from the collarbone
down to the diaphragm. The
right lung is divided into
three sections, or lobes. The
left lung, with a cleft to
accommodate the heart, has
only two lobes. The two
branches of the trachea,
called bronchi, subdivide
within the lobes into smaller
and smaller air vessels
known as bronchioles.
Bronchioles terminate in
alveoli, tiny air sacs
surrounded by capillaries.
When the alveoli inflate with
inhaled air, oxygen diffuses
into the blood in the
capillaries to be pumped by
the heart to the tissues of
the body. At the same time
carbon dioxide diffuses out
of the blood into the lungs,
where it is exhaled.

Alveoli

A scanning electron
micrograph reveals the tiny
sacs known as alveoli within
a section of human lung
tissue. Human beings have a

E. Alveoli
The bronchioles divide many more times in the lungs to create an impressive tree with smaller and
smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air
sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide.
Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and
remove foreign substances that have not been filtered out earlier. The macrophages are the last line of
defense of the respiratory system; their presence helps ensure that the alveoli are protected from infection so
that they can carry out their vital role.
The alveoli number about 150 million per lung and comprise most of the lung tissue. Alveoli resemble
tiny, collapsed balloons with thin elastic walls that expand as air flows into them and collapse when the air is
exhaled. Alveoli are arranged in grapelike clusters, and each cluster is surrounded by a dense hairnet of tiny,
thin-walled capillaries. The alveoli and capillaries are arranged in such a way that air in the wall of the alveoli
is only about 0.1 to 0.2 microns from the blood in the capillary. Since the concentration of oxygen is much
higher in the alveoli than in the capillaries, the oxygen diffuses from the alveoli to the capillaries. The oxygen
flows through the capillaries to larger vessels, which carry the oxygenated blood to the heart, where it is
pumped to the rest of the body.
Carbon dioxide that has been dumped into the bloodstream as a waste product from
cells throughout the body flows through the bloodstream to the heart, and then to the alveolar
capillaries. The concentration of carbon dioxide in the capillaries is much higher than in the
alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation forces the carbon dioxide
back through the respiratory passages and then to the outside of the body.

MANAGEMENT
Medical Management

Pharmacologic Management
1. Pulmonary TB is treated with chemotherapeutic agents (antituberculosis agents) for 6-12
months
2. Identify 3 types of Resistance

Primary Resistance

- resistance to one or first line antituberculosis agents in people who have not had
previous treatment.

Secondary or Acquired Drug Resistance

- resistance to one or more antituberculosis agents in patients undergoing therapy.

Multidrug Resistance
-resistance to 2 agents, Isoniazid (INH) and rifampicin

First line anti-TB drug

R- Rifampicin
I- Isoniazid
P- Pyrazinamide
E- EthambutoL

Combined Medications
1. INH and Rifampin (Rifamate)
2. INH, Rifampin, Pyrazinamide (Rifater)

Second line Anti-TB agent

1. Capreomycin
2. Ethionamide
3. Para-aminosalicyclate sodium
4. Cycloserine

Other Medications
1. Aminoglycosides
2. Quinolones
3. Rifabutin
4. Clofazimine

Phases of treatment
1. Initial Phase 8 weeks
2. Continuation Phase- lasts for additional 4-7 months

Drugs

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

Streptomycin

Side Effects
-body fluid discoloration
-hepatotoxic
-permanent discoloration of contact lenses
-peripheral neuropathy
(Give Vit. B6/ Pyridoxine)
-Hyperurecemia/ gouty arthritis
(Increase fluid intake)
-Optic Neuritis
-Blurring of vision
(Not to be given to children below 6 years old
due to inability to complain of blurring of
vision)
-Damage to the 8th Cranial nerve
-Ototoxic
-Tinnitus
-Nephrotoxic

Category 1
Category 2
Category 3
Intensive Phase RIPE ( 2 mo.s) Intensive Phase RIPE ( 3 mo.s) Intensive Phase RIPE ( 2 mo.s)
Continuation Phase RI ( 4 mo.s)Continuation Phase RI ( 5 mo.s)Continuation Phase RI ( 4 mo.s)
(-)smear with extensive
Treatment failure
(-)smear PTB with minimal
Relapse
parenchymal lesions
lesions on CXR
Return after default
Extrapulmonary TB
Same meds with Category 1
Severe concominant HIV
disease

NURSING INTERVENTION
Promoting Airway Clearance
Increasing the fluid intake promotes systemic hydration and serve as an effective expectorant.
The nurse instruct the patient about the correct positioning to facilitate airway drainage (postural
drainage)
Advocating adherence to Treatment Regimen
Understanding of the medications, schedule, and side effects is important.
(The pt. must understand that TB is a communicable disease and that taking medications is the most
effective means of preventing transmission. The major reason tx fails that pt. do not take their
medications regularly & for the prescribed duration.)
Educate on the importance of hygenic measures including mouth care, covering the mouth & nose
when coughing & sneezing, proper disposal of tissues & handwashing.
Promoting Activity & Adequate Nutrition
Planning a progressive activity schedule that focuses on increasing activity tolerance and muscle
strength.
Prepare a nutritional plan allowing small, frequent meals because the pt. willingness to eat may be
altered by fatigue from excessive coughing and sneezing, sputum production, chest pain, generalized
debilitated state, or cost, if the pt. has few resources.
Liquid nutritional supplements may assist in meeting basic caloric requirements.
Monitoring and Managing Potential Complications
Malnutrition
Malnutrition may be a consequence of the patients lifestyle, lack of knowledge about adequate
nutrition and its role in health maintenance, lack of resources, fatigue, or lack of appetite because of
coughing and mucus production.
To counter the effects of these factors, the nurse collaborates with the dietitian, physician, social
worker, family and patient to identify strategies to ensure an adequate nutritional intake and
availability of nutritious food.
High-calorie nutritional supplements may be suggested as a strategy for increasing dietary intake using
food products normally found in the home.
Side effects of Medication Therapy
It is important to assess medication side effects, they are often a reason why patients fail to adhere to
the prescribed medication regimen. Efforts are made to reduce side effects and motivate the pt. to
take medications as prescribed.
The nx instruct the pt. to take medication either on an empty stomach or atleast 1hr before meals,
because food interferes with the medication absorption (although taking meds on an empty stomach
can cause GI upset).
Patient taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese,red
wine, soy sauce, yeast extracts) because eating them while taking INH may result in headache,
flushing hypotension,lightHeadedness, palpitation, and diaphoresis.
In addition, Rifampin can increase the metabolism of certain other medications, making them less
effective. These meds include: beta-blockers, oral anticoagulants such as warfarin( Coumadin),
digoxin, quinidine, corticosteroids, oral hypoglycemic agents, oral contraceptives, theophylline, and
verapamil (Calan, Isoptin).
The nurse may inform the pt. that rifampicin may discolor contact lenses and the patient may want to
wear eyeglasses during treatment.
The nurse monitors for other side effects of anti-TB medications, including hepatitis, neurologic
changes, and rash.
Liver enzymes, BUN, and serum creatinine levels are monitored to detect changes in liver and kidney
function.
Sputum culture results are monitored for acid-fast bacilli to evaluate the effectiveness of the treatment
regimen and adherence to therapy.
Multidrug Resistance

The nurse carefully monitors vital signs and observes for spikes in temperature or changes in the
patients respiratory status are reported to the primary health care provider.

The nurse instructs the patient about the risk of drug resistance if the medical regimen is not strictly
and continuously followed.

Spread of Tuberculosis Infection

The nurse monitors vital signs and observe for spikes in temperature as well as changes in renal and
cognitive function. Few physical signs may be elicited on physical examination of the chest, but at this
stage the patient has a severe cough and dyspnea. Treatment of military TB is the same as for
pulmonary TB.

Promoting Home and Community Based Care

Teaching patient self-care

The nurse instructs the patient and family about infection control procedures, such as proper disposal
of tissues, covering the mouth during coughing, and frequent handwashing.
Assessment on the patients adherence to the medication regimen is essential because of the risk of
emergence of resistance m nif the regimen is not followed faithfully.
In some cases, the patients ability to comply with the medication regimen is in question, referral to an
outpatient clinic for daily medication administration may be required. This is referred to as directly
observed therapy. (DOT)

Continuing care

The nurse evaluates the patients environment, including the home, or workplace and social setting, to
identify other people who may have been in contact with the patient during the infectious stage.
It is important to arrange follow-up screening for any such contacts. The nurse who has contact with a
patient in the home, shelter , hospital, clinic or work setting continue to assess the patients physical
and psychological status and ability to adhere to the prescribed treatment.
The nurse also assesses the patient for adverse effects of medications and adherence to the
therapeutic regimen.
In addition, the nurse reinforces the previous teaching, emphasizes the importance of keeping
scheduled appointments with the primary health care provider, and reminds the patient about the
importance of other health promotion activities and recommended health screening.