Pulmonary tuberculosis

(TB)

Presented By
Dr. Heba Abd El Reheem
 Objectives
• Define tuberculosis.
• Stat method of transmission of tuberculosis.
• Identify causes and risk Factors for Tuberculosis
• Identify pathophysiology of tuberculosis.
• Identify types of tuberculosis.
• Describe clinical manifestation of tuberculosis.
• Identify diagnostic evaluation of tuberculosis.
• Identify treatment of tuberculosis
• Stat expected duration of tuberculosis.
• Explain management of tuberculosis.
 Definition
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 (the membranes that cover the brain),
kidneys, bones, lymph nodes, and the membrane
covering the digestive organs (peritoneum).
The primary infectious agent, Mycobacterium
,tuberculosis
 Methods of transmission
TB spreads from person to person by airborne-
.transmission

An infected person releases droplet nuclei through-

.talking, coughing, sneezing, laughing, or singing
Larger droplets settle; A process of evaporation -
leaves small droplet nuclei, 1 to 5 μm in size,
(micrometers in diameter), suspended in the air for
.minutes to hours
These droplet nuclei are then transmitted via -
.inhalation to another person(susceptible person)
TB is not highly infectious, and transmission usually-
.requires close, frequent, or prolonged exposure
Brief exposure to a few tubercle bacilli rarely-
.causes an infection

The disease cannot be spread by touching, sharing-

food utensils, kissing, or any other type of physical
.contact
Factors that in uence the likelihood of transmission
: include
,number of organisms expelled into the air (1)
concentration of organisms (small spaces with (2)
limited ventilation
,length of time of exposure (3)
.immune system of the exposed person (4)
 Causes

The primary infectious agent, Mycobacterium

tuberculosis, (Tubercle bacilli ) are gram
positive, rod shaped, acid-fast, and aerobic.
that grows slowly and is sensitive to heat and
ultraviolet light.
M. tuberculosis is an acid fast bacillus (AFB), which-
means that when it is stained in the laboratory and
then washed with an acid, the stain remains, or
”.stays “fast

Although they can live in the dark for months -

,as spores in particles of dried sputum
exposure to direct sunlight, heat, or ultraviolet-
.light destroys them in a few hours
They are difficult to kill with ordinary -
disinfectants and are destroyed by
pasteurization, a process widely used in milk
.and milk products to prevent the spread of TB

It is spread by inhalation of the tuberculosis bacilli -

from respiratory droplets (droplet nuclei) of an
.infected person
 Pathophysiology

,Droplet nuclei with bacilli are inhaled

.enter the lung, and deposit in alveoli
Macrophages and T lymphocytes act together to try
;to contain the infection by forming granulomas

off The formation of a granulomais a defense mechanism aimed at walling)

the infection and preventing further spread. Replication of the bacillus is
.inhibited and the infection is stopped
In weaker immune systems, (5% to 10% of these
individuals, go on to develop active TB infection when the
bacteria begin to multiply months or years later.M. tuberculosis
is aerophilic (oxygen loving) and thus has an affinity for the
lungs. the wall loses integrity and the bacilli are able to
.escape and spread to other alveoli or other organs
 The Difference Between Latent TB
Infection and TB Disease
A PERSON WITH LATENT TB INFECTION
Does not feel sick -
Has no symptoms -
Cannot spread TB bacteria to others -
Usually has a positive TB skin test or positive TB -
blood test
Has a normal chest x-ray and a negative sputum -
smear
Should consider treatment for latent TB infection -
.to prevent TB disease
If not treated properly, a person who has TB infection *
.can develop TB disease
A PERSON WITH TB DISEASE
Usually feels sick -
:Has symptoms that may include -
A bad cough that lasts 3 weeks or longer *
Pain in the chest *
Coughing up blood or sputum *
Weakness or fatigue *
Weight loss *
No appetite *
Chills *
Fever *
Sweating at night *
.May spread TB bacteria to others -

Usually has a positive TB skin test or positive TB -

.blood test

May have an abnormal chest x-ray, or positive -

.sputum smear or culture

Needs treatment for TB disease -

If a person develops TB disease and does not get *
.appropriate medical treatment he/she can die
 Risk Factors for Tuberculosis
.Close contact with someone who has active TB-1
Inhalation of airborne nuclei from an infected-2
in person is proportional to the amount of time spent
the same air space, the proximity of the
.person, and the degree of ventilation
Immuno-compromised status (e.g, those with HIV -3
infection ,cancer , transplanted organs, and
prolonged high-dose corticosteroid therapy)
Substance abuse (IV or injection drug users and -4
alcoholics)
Any person without adequate health care (the -5
homeless; impoverished; minorities, particularly
children under age 15 years and young adults
between ages 15 and 44 yrs)
Preexisting medical conditions or special-6-
treatment (e.g, diabetes, chronic renal failure,
malnourishment, selected malignancies,
hemodialysis ,transplanted organ, gastrectomy, or
jejunoileal bypass)
Immigration from countries with a high -7-
prevalence of TB (southeastern Asia, Africa, Latin
America, Caribbean)
Institutionalization (eg, long-term care facilities, -8
psychiatric institutions, prisons)
Living in overcrowded, substandard housing -9
Being a health care worker performing -10
:high-risk activities
administration of aerosolized pentamidine and
other medications, sputum induction procedures,
bronchoscopy, suctioning, coughing procedures,
caring for the immunosuppressed patient, home
care with the high-risk population, and
administering anesthesia and related procedures
(e.g, intubation, suctioning)
 Pathophysiology
• A susceptible person inhales mycobacterium bacilli
and becomes infected.

• The bacteria are transmitted through the airways to

the alveoli, where they are deposited and begin to
multiply.

• The bacilli also 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 body’s immune system responds by initiating an
inflammatory reaction. Phagocytes (neutrophils and
macrophages) engulf many of the bacteria, and
TB-specific lymphocytes lyses (destroy) the bacilli and
normal tissue.

• This tissue reaction results in the accumulation of

exudate in the alveoli, causing bronchopneumonia

• The initial infection usually occurs 2 to 10 weeks after

exposure.

• Granulomas, new tissue masses of live and dead

bacilli, are surrounded by macrophages, which form a
protective wall around the granulomas.
• Granulomas are then transformed to a fibrous tissue
mass, the central portion of which is called a 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, the person may
develop active disease because of a compromised or
inadequate immune system response.

• Active disease also may occur with reinfection

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 extends
to adjacent lobes. The process may be prolonged and
characterized by long remissions

• when the disease is arrested, only to be 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 within the lungs, usually in the apical or
posterior segments of the upper lobes, or the superior
segments of the lower lobes.
 Types of tuberculosis
1. Primary pulmonary tuberculosis
• If the initial immune response is not adequate, the
body cannot contain the organisms, the bacteria
replicate, and active TB disease results.
• When active disease develops within the first 2 years
of infection, it is termed primary TB.
• This type of active tuberculosis is most common in
infants and children, especially in developing countries
with high rates of malnutrition and poor medical care.
People with HIV and other diseases that suppress the
immune system are also at risk.
 2. Post primary (reactivation) tuberculosis
• is defined as TB disease occurring 2 or more
years after the initial infection.
• About 95% of people infected with tuberculosis
can inactivate the disease at first.
• Most of them never develop active disease. In
those that do, the bacteria eventually overcome
the immune system and begin to replicate and
spread, usually in the lungs.
• The bacteria may destroy large areas of the lungs,
forming cavities filled with bacteria and dead cells.
 3. Extra pulmonary tuberculosis.
• Tuberculosis is primarily an infection of the lungs but
the organisms may spread and cause infection in other
parts of the body as: bones, meninges, genitourinary
tract, lymph nodes, pleurae, pericardium, abdomen, and
endocrine glands.
• M. tuberculosis infection outside the lungs is called
extrapulmonary tuberculosis.

4. Disseminated or miliary tuberculosis.

Tuberculosis can spread through the entire body
by way of the bloodstream.
 CLASSIFICATION OF TB
▪Data from the history, physical examination, TB test,
chest x-ray, and microbiologic studies are used to
classify TB into one of five classes.
❑Class 0: no exposure; no infection
❑Class 1: exposure; no evidence of infection
❑Class 2: latent infection; no disease (eg,
positive purified protein derivative (PPD) reaction
but no clinical evidence of active TB)
❑Class 3: disease; clinically active
❑Class 4: disease; not clinically active
❑Class 5: suspected disease; diagnosis pending
 diagnostic evaluation of
tuberculosis
▪ Tuberculosis can be a difficult disease to
diagnose, mainly due to the difficulty in
culturing this slow-growing organism in the
laboratory (4–12 ) weeks for blood culture.

▪ A complete medical evaluation for TB must

include a medical history, a physical
examination
• Asking about symptoms such as cough, fever, weight
loss, night sweats, swollen glands and breathing
problems.

• Exposed to anyone with tuberculosis.

▪ Examination of the lungs by stethoscope can

reveal crackles (unusual breath sounds). Enlarged
or tender lymph nodes may be present in the neck
or other areas. Fluid may be detectable around a
lung. Clubbing of the fingers or toes may be
present.
 Tests may include:

•Chest x-ray

•Sputum cultures

•Acid-fast bacillus smear (the acid-fast bacillus smear

contains mycobacteria.)

•Tuberculin skin test

•Bronchoscopy
•A test called PCR (polymerase chain reaction) also can be
used to check for tuberculosis infection.

•Other body fluids (such as fluid from the space around

the lungs ) also may be tested for tuberculosis bacteria
(Thoracentesis).

•Chest CT

•Interferon-gamma blood test such as the QFT-Gold test

•Biopsy of the affected tissue (rare (

A chest X-ray usually is done if you have:

•A positive tuberculin skin test

•Symptoms of active TB, such as a persistent
cough, fatigue, fever, or night sweats.
•An uncertain reaction to the tuberculin skin test
because of a weakened immune system, or to a
previous bacille Calmette-Guerin (BCG)
vaccination.
 Acid-fast bacillus smear (AFB)
• AFB smear refers to the microscopic examination of
a fluorochrome stain of a clinical specimen
• Specimen Collection: Sputum
1- An early morning, deep cough specimen
collected on three (3) consecutive days is best for
initial diagnosis of tuberculosis
2- If sputa(mucous) are collected within the same
24-hour period, a minimum of eight (8) hours
between specimens is required
Keep each sputum specimen covered and -
refrigerated or delivered to the laboratory
.within 1 hour
.Use a new sterile container for each collection -

3- Minimum acceptable specimen volume is two (2)

mL and Refrigerate until shipped
 Sputum cultures
• A sputum culture is done to find the best
antibiotic to treat the infection.

• How To Prepare: Do not use mouthwash

before you collect your sputum sample. Some
types of mouthwash can kill bacteria and
could affect your results
 Tuberculin skin test (The Mantoux test )
The Mantoux test is used to determine if a person has *
.been infected with the TB bacillus

The Mantoux test is a standardized procedure and should *

be performed only by those trained in its administration
.and reading

,Tubercle bacillus extract (tuberculin) *

purified protein derivative (PPD), is injected into the *

intradermal layer of the inner aspect of the forearm,
approximately 4 inches below the elbow (0.1 mL of PPD is
.injected (Fig. )
Tuberculin skin test
 Tuberculin skin test
( Mantoux test for tuberculosis)

Correct technique for inserting the needle involves depositing the (A)
.PPD subcutaneously with the needle bevel facing upward
The reaction to the Mantoux test usually consists of a wheal, a (B)
.hivelike, firm welt
To determine the extent of the reaction, the wheal is measured using a (C)
commercially prepared gauge. A wheal measuring 5 mm or more is
.considered significant
. You will need to return within 48-72 hours to
observe reaction ( induration (hardening) and
arrhythmia ).

. Tests read after 72 hours tend to underestimate

the true size of induration (hardening).

• A delayed localized reaction indicates that the

person is sensitive to tuberculin.
A reaction occurs when both induration and erythema-
.(redness)are noted

After the area is inspected for induration, it is lightly -

palpated across the injection site, from the area of
.normal skin to the margins of the induration
The diameter of the induration(not erythema) is -
measured in millimeters at its widest part and the size
.of the induration is documented

Erythema without induration is not considered -

.significant

The size of the induration determines the -

.significance of the reaction
.Interpretation of Results
A reaction of 0 to 4 mm is considered not -
;significant
A reaction of 5 mm or greater may be significant in --
.individuals who are considered at risk
An induration of 10 mm or greater is usually --
considered significant in individuals who have normal
.or mildly impaired immunity
A significant reaction indicates that a patient has been
exposed to M. tuberculosis recently or in the past or has
been vaccinated with bacille Calmette-Guerin (BCG)
.vaccine
 The new test for TB
Interferon-γ Release Assays. Interferon-γ (INF-γ)
release assays (interferon-gamma release
assays) (IGRAs),: (IGRAs) provide another
.screening tool for TB
These whole blood assays detect INF-γ released
from T lymphocytes in response to mycobacterial
.antigens
and Examples of IGRAs include QuantiFERON-TB test
.the T-SPOT.TB test
Test results are available in a few hours
 The new test for TB
• Named QuantiFERON-TB (QTB):
• The blood tests are interferon-gamma release
assays (IGRAs), which include the
QuantiFERON-TB Gold
• In-Tube test, the QuantiFERON-TB Gold test,
and the T-SPOT.TB test. IGRA results are
available in 24 hours.
Draw blood sample and placed on the
chambers with mycobacterial antigen
If positive (lymphocytes secret (y interferon) and
a cytokine produced by lymphocyts
 Complications
• permanent lung damage if not treated early
• Spread of the tuberculosis bacilli throughout the body
can result in :
• pleurisy,
• pericarditis,
• peritonitis,
• meningitis,
• bone and joint infections,
• genitourinary or gastrointestinal infection, or infection
of many other organs.
• Medicines used to treat TB may cause side
effects, including:
• non-infectious hepatitis ,
• an orange or brown coloration of tears and
urine,
• neurologic changes (deafness or neuritis),
• skin rash and
• gastrointestinal upset.
• Malnutrition

• Multidrug resistance

• Spread of TB infection (miliary TB)

 Management of tuberculosis
Treatment
• Pulmonary TB is treated primarily with
chemotherapeutic agents (antituberculosis
agents) for 6 to 12 months. A prolonged
treatment duration is necessary to ensure
eradication of the organisms and to prevent
relapse.

• The goal of treatment is to cure the infection

with drugs that fight the tuberculosis bacteria
❖You may need to be admitted to a hospital
to prevent the spread of the disease to
others until you are no longer contagious.

❖ Incomplete treatment of TB infections (such as

failure to take medications for the prescribed
length of time) can contribute to the emergence
of drug-resistant strains of bacteria.
❖ Treatment for TB uses antibiotics to kill the
bacteria.

❖ The two antibiotics most commonly used are

rifampicin and isoniazid.

❖ However, instead of the short course of

antibiotics typically used to cure other bacterial
infections, TB requires much longer periods of
treatment (around 6 to 12 months) 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.
NURSING PROCESS:THE PATIENT WITH
T.B
Assessment

• The nurse performs a complete history and

physical examination.

• Clinical manifestations of fever, anorexia,

weight loss, night, sweats, fatigue, cough,
and sputum production
 Nursing Diagnoses
Based on the assessment data, the nursing diagnoses
may include:

• Ineffective airway clearance related to copious

tracheobronchial secretions

• Deficient knowledge about treatment regimen and

preventive health measures and related ineffective
individual management of the therapeutic regimen
(noncompliance)

• Activity intolerance related to fatigue, altered nutritional

status, and fever
 Nursing Interventions
• Promoting airway clearance
• Advocating adherence to treatment regimen
• Promoting activity and adequate nutrition
• Monitoring and managing potential
complications
- Malnutrition
- Side Effects of Medication Therapy
- Multidrug Resistance
- Spread of TB Infection
• Promoting home and community-based care
Promoting airway clearance; through .1
Monitor breath sounds, respiratory rate, •
.sputum production and dyspnoea
.Provide supplementary oxygen as ordered •
Encourage the patient to assume comfortable •
position to decrease dyspnea
Encourage high level of fluid intake ( 8 to 12 •
.glasses; 2 to 3 liters daily) if not contraindicated
Postural drainage •
;Advocating adherence to treatment regimen .2
Administer and teach self-administration of •
medication as ordered
Stress the importance of continuing to take •
.medication for prescribed time
Instructs the patient about important .3
hygiene measures, including
,mouth care •
covering the mouth and nose when coughing •
,and sneezing
,proper disposal of tissues •
.and hand hygiene •
 Promoting activity and adequate nutrition .4
.Encourage rest and avoidance of exertion •
Encourage and explain the importance of •
.eating a nutritious
.Monitor weight •
Administer vitamin supplements as ordered, •
particularly pyridoxine (Vitamin B12) to prevent
.isonized peripheral neuropathy in-patient taking
 Prevention
TB is a preventable disease, even in those who-1
.have been exposed to an infected person

Clean, well-ventilated living areas are essential-2

.to the health of all people

If a hospitalized patient is known or suspected-3

to have tuberculosis, he or she is placed in
or respiratory isolation to prevent spread to staff
other patients
Special negative-pressure isolation rooms are-4
.ventilated to the outside

Staff should wear special high-efficiency-5

filtration masks when in the patient’s room; a
.regular surgical mask is not effective against TB

Verify with the institution’s infection control-6

department that the masks provided are
.effective for use with TB patients
If the patient must travel through the hallway-6
for tests or other activities, he or she must wear
.a mask

Additional protective barriers, such as gowns,-7

gloves, or goggles, are used when contact with
.sputum is likely

Individuals exposed to tuberculosis should be-8

skin tested immediately and a follow-up test
should be done at a later date, if the initial test
.is negative
Prompt treatment is extremely important in-9
controlling the spread of tuberculosis for those who
.have already progressed to active TB disease

It is therefore vital to teach all patients the-10

importance of strict compliance with drug therapy
Ultimately, prevention will come from adequate
.treatment of patients with TB

A current concern is the development of-11

antibiotic-resistant strains of the tuberculosis
bacillus, which can develop when patients are
.noncompliant with drug therapy
Bacille Calmette–Guerin (BCG) vaccination to-12
high prevent TB is given in some countries with a
incidence of TB, but its effectiveness remains
controversial. It is not routinely used in the
United States. People who have had BCG may
still be skin tested for TB and results of testing (if
positive) discussed with one's doctor
 Remember…
► TB infection occurs when a person has breathed in
the TB germ, but the person is not sick.

► TB disease can develop in a person with TB

infection if they do not get medical treatment.

► A person with TB disease is sick and may have

several symptoms of the disease.

► If left untreated, persons with TB disease can die

from TB.