tb

1. Clinical Features Of
Pulmonary Tuberculosis AND
RNTCP
Deptt.Of Pulmonary Medicine
Jawaharlal Nehru Medical College

3. Learning Objectives
• Describe common symptoms
• Differential diagnosis of Cough, hemoptysis, dyspnea
• Common clinical signs

4. COMPETENCY
• CT1.14
• CT1.15

5. Introduction
• Patient may develop symptoms insidiously and some may
remain asymptomatic
• Patient with TB present with constitutional and respiratory
symptom
• Constitutional symptoms: tiredness, headache, weight loss,
fever, night sweats and loss of appetite
• Classic sign and symptom of TB are significantly higher
proportion in younger than elderly : fever (62% vs 31%),
weight loss (76% vs 34%), night sweats (48% vs 6%),
sputum production (76% vs 48%) and hemoptysis (40 %
vs 17%)

6. Cough: Definition
• Cough is an explosive expiration that provides a normal
protective mechanism for clearing the tracheobronchial
tree of secretions and foreign material.

7. Cough-Types
Cough is mainly classified as:
a) Productive / Useful / Effective
 It used to drain secretions or mucous from the lungs.
 This type of cough is mostly acute in nature and often
caused by bacterial or viral or fungal infection.
 This type of cough should not be suppressed because here
the purpose of the cough is to remove mucus from
airways.
 Suppression of this type of cough leads to recurrent or
constant infection.

8. Cough can also be classified as:
 Acute - less than three weeks duration eg. infective
cough
 Chronic - more than three weeks duration - for example,
smoker’s cough
 Paroxysmal cough - spasmodic and recurrent
 Bovine cough - soundless cough due to paralysis of larynx
 Psychogenic cough - self-conscious activity of the patient
to draw attention

9. Cough Reflex
 Coughing may be initiated either voluntarily or reflexively
and has both afferent and efferent pathways.
 The afferent limb includes receptors within the sensory
distribution of the trigeminal, glossopharyngeal, superior
laryngeal, and vagus nerve in the nose, nasopharynx,
larynx, auditory canal, trachea, pulmonary bronchus and
pleura.
 They report about the excess mucous or foreign substance
to the cough center which is located in the medulla of the
brain for inducing cough.

10. Cough Reflex contd…
 Receptors are sensitive to
 Touch of inhaled foreign body
 Irritant gases like nitric acid, sulphuric acid, ammonia
 Excessive secretions or mucous in nose, throat, sinuses
and lungs
 Oedema or infection with pus in the airway
 Exposure to extreme hot or cold air
 The efferent limb includes the recurrent laryngeal nerve
and the spinal nerves.
 The cough starts with a deep inspiration followed by
glottic closure, relaxation of the diaphragm, and muscle
contraction against a closed glottis.

11. Cough Reflex contd…
 The resulting markedly positive intrathorasic pressure
causes narrowing of the trachea.
 Once the glottis opens, the large pressure differential
between the airways and the atmosphere coupled with
trachea narrowing produces rapid flow rates through the
trachea.
 The shearing forces that develop aid in the elimination of
mucus and foreign materials.
 Normally, people cough voluntarily once or twice during
early morning or daytime to clear the throat or lungs.

12. ETIOLOGY
a) Infection - bacteria, virus and fungus.
b) External factors - by dust, cold, pollens, smoking and other
environmental irritants.
c) Drugs of hypertension and heart diseases (ACE inhibitors, beta
blockers).
d) Foreign body in the pharynx, nose, larynx, trachea, bronchus,
oesophagus.
e) Internal factors -
Sinuses - Postnasal drip
Heart - Congestive heart failure
Lung - Asthma, chronic bronchitis, cancer, emphysema,
bronchiectasis, tuberculosis
Pressure on lung- mediastinal lymphadenopathy,aneurysm,
thyromegaly
Ear - Otitis media, CSOM, impacted cerumen and foreign body
Stomach - Gastro oesophageal reflux
f) Psychogenic factors - habit of clearing mucous, for drawing
attention.

13. TYPES OF COUGH (contd..)
b) Non-productive / Ineffective / Dry
 It is a dry, irritating cough without bring any secretions
or mucous from the lungs
 This type of cough is chronic in nature and caused by dry
irritation or dust or smoke or fumes, or due to oedema
and mild secretion in the resolving stage of illness.
 It may be also due to weakness of the muscles of
respiration, thick viscid mucus and in diseases of the cilia
which helps mucous transportation in the airway.

14. Tuberculosis and Cough
• Cough : MC symptom,
• Dry or productive
• Expectoration: mucoid, mucopurulant, purulant or blood
tinged and is usually scanty
• Cough of more than 2 wks duration should be investigated
for tuberculosis.

15. Massive hamoptysis
 Definition of massive hemoptysis is variable in the
literature and has ranged from 100 mL/24 hrs to 1000
mL/24 hrs. The most commonly accepted definition of
massive hemoptysis is 600 mL/24 hrs.
 Life-threatening process requiring immediate evaluation
and treatment.
 1.5- 5% of all patients presenting with hemoptysis.
 Mortality: 7-30%
 Source of massive hemoptysis is usually systemic(95%)
rather than pulmonary circulation (5%).

16. Vascular origin of hemoptysis
 Blood traversing the lungs can arrive from
pulmonary arteries, or
bronchial arteries
 Virtually the entire cardiac output courses through the low-
pressure pulmonary arteries and arterioles en route to being
oxygenated in the pulmonary capillary bed .
 In contrast, the bronchial arteries are under much higher systemic
pressure but carry only a small portion of the cardiac output

17. Vascular origin of hemoptysis
 Despite the quantitatively smaller contribution of the
bronchial circulation to pulmonary blood flow, the
bronchial arteries are generally a more important source of
hemoptysis than the pulmonary circulation.
 In addition to being perfused at a higher pressure, they also
supply blood to the airways and to lesions within the
airways.

18. Differential diagnosis

19. Tuberculosis and Hemoptysis
Tuberculosis can cause massive hemoptysis through multiple
mechanisms
In active disease
 Endobronchitis
 Rupture of Rasmussen’s aneurysm
 Oozing from the wall of active pulmonary cavitary lesions
 Invasion of blood vessels by active granulation tissue
In healed disease
 Impigement of healed calcified lymph node on bronchial artery
 Bleeding from the wall of a cavity with mycetoma
 Scar carcinoma
 Bronchiectatic lesions

20. DYSPNEA
• Dyspnea refers to the sensation of difficult or
uncomfortable breathing when the patient becomes aware
of his own breathing. It is a subjective experience
perceived and reported by an affected patient.
• Dyspnea on exertion (DOE) may occur normally, but is
considered indicative of disease when it occurs at a level of
activity that is usually well tolerated
• Dyspnea should be differentiated from tachyapnea,
hyperventilation, and hyperpnoea, which refer to
respiratory variations regardless of the patient’s subjective
sensations.

21. MEDICAL RESEARCH COUNCIL DYSPNOEA SEVERITY SCALE
Grade Degree Characteristics
0 None Only with strenuous activity
1 Slight
When hurrying on level ground or climbing
a slight incline
2 Moderate
Needs to walk more slowly than others of
the same age or has to stop for breath
when walking at own pace on level ground
3 Severe
Stops for breath after 100 yards or after a
few minutes
4 Very severe
Housebound or dyspnea when dressing or
undressing

22. Tuberculosis and Dyspnea
• In TB, Breathlessness is due to extensive disease
(parenchymal loss or decreased researve) or if
complication such as bronchial obstruction, pneumothorax
or pleural effusion occurs