Pulmonarytuberculosisppt

PRESENTED BY;
ANUPAMA.T
IIND YEAR MSC NURSING
SARVODAYA COLLEGE OF
NURSING
BANGALORE

Tuberculosis (TB) is one of the most
prevalent infections of human beings and
contributes considerably to illness and
death around the world. It is spread by
inhaling tiny droplets of saliva from the
coughs or sneezes of an infected person.It
is a slowly spreading, chronic,
granulomatous bacterial infection,
characterized by gradual weight loss
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Tuberculosis is the infectious
disease primarily affecting lung
parenchyma is most often caused
by mycobacterium tuberculosis.
It may spread to any part of the
body including meninges, kidney,
bones, adrenal glands, larynx and
lymph nodes and can be
disseminated throughout the
body.
3

 Respiratory system constitutes of nose, pharynx,
larynx, trachea, two bronchi, bronchioles and
smaller air passages, two lungs and their coverings,
the pleura.
LUNGS :
 Position and associated structures
There are two lungs, one lying on each side of the
midline in the thoracic activity.
 They are cone shaped and are having
-an apex
-a base
- Costal surface.
-the medial surface.
 Organisation of the lungs.
Right lung is divided into three distinct lobes.
Superior, middle, inferior.
 -Left lung is smaller as heart is situated left to
the midline into superior lobe and inferior lobe.
6

Mycobacterium tuberculosis
Droplet
nuclei(coughing,sneezing,laughi
ng)
Exposure to TB
8

 CLOSE CONTACT WITH SOME ONE WHO HAVE
ACTIVE TB.
 IMMUNO COMPROMISED STATUS
(ELDERLY,CANCER)
 DRUG ABUSE AND ALCOHOLISM
 PEOPLE LACKING ADEQUATE HEALTH CARE
 PRE EXISTING MEDICAL CONDITIONS
(DIABETES MELLITUS,CHRONIC RENAL
FAILURE)
 IMMIGRANTS FROM COUNTRIES WITH
HIGHER INCIDENCE OF TB.
 INSTITUTIONALISATION(LONG TERM CARE
FACILITIES)
m
9

 LIVING IN SUBSTANDARD CONDITIONS
 OCCUPATION(HEALTH CARE WORKERS)
10

(INITIAL INFECTION OR PRIMARY INFECTION)
ENTRY OF MICRO ORGANISM THROUGH DROPLET NUCLEI
BACTERIA IS TRANSMITTED TO ALVEOLI THROUGH AIRWAYS
DEPOSITION AND MULTIPLICATION OF BACTERIA
BACILLI ARE ALSO TRANSPORTED TO OTHER PARTS OF THE BODY
THROUGH BLOOD STREAM AND LYMPHNODE
INFLAMMATION
11

 PHAGOCYTOSIS BY NEUTROPHILS AND MACROPHAGES
 ACCUMULATION OF EXUDATE IN ALVEOLI
 BRONCHO PNEMONIA
 NEW TISSUE MASSES OF LIVE AND DEAD BACILLI ARE
SURROUNDED BY MACROPHAGES WHICH FORM A PROTECTIVE
MASS AROUND GRANULOMAS
 GRANULOMAS THEN TRANSFORMS TO FIBROUS TISSUE MASS
AND CENTRAL PORTION OF WHICH IS CALLED GHON
TUBERCLE
12

 THE MATERIAL (BACTERIA AND MACROPHAGES BECOMES
NECROTIC FORMING CHEESY MASS
 MASS BECOMES CALCIFIED AND BECOMES COLAGENOUS SCAR
 BACTERIA BECOME DORMANT AND NO FURTHER
PROGRESSION OF ACTIVE DISEASE
 (ACTIVE DISEASE OR RE INFECTION)
 INADEQUATE IMMUNE RESPONSE
 ACTIVATION OF DORMANT BACTERIA

 GHON TUBERCLE ULCERATES AND RELEASING CHEESY MATERIAL
INTO BRONCHI
 BACTERIA THEN BECOME AIRBORNE RESULTING IN FURTHER SPREAD OF
INFECTION
 ULCERATED TUBERCLE HEALS AND BECOMES SCAR TISSUE
 INFECTED LUNG BECOME INFLAMMED
 FURTHER DEVOLOPMENT OF PNEUMONIA AND TUBERCLE FORMATION
 UNLESS THE PROCESS IS ARRESTED IT SPREADS DOWNWARDS TO THE HILUM
OF LUNGS AND LATER EXTENDS TO ADJASCENT LOBES
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1)CONSTITUTIONAL SYMPTOMS
 Anorexia
 Low grade fever
 Night sweats
 Fatigue
 Weight loss.
2) PULMONARY SYMPTOMS
Dyspnea
Non resolving bronchopneumonia
Chest tightness
Non productive cough
Mucopurulent sputum with hemoptysis
Chest pain
3) EXTRA PULMONARY SYMPTOMS
 Pain
 Inflammation.

1.HISTORY COLLECTION
2.PHYSICAL EXAMINATION
 Clubbing of the fingers or toes (in people with advanced disease)
 Swollen or tender lymph nodes in the neck or other areas
 Fluid around a lung (pleural effusion)
 Unusual breath sounds (crackles)

-A physical exam may also show:
 Swollen liver
 Swollen lymph nodes
 Swollen spleen

Tests may include:
 Biopsy of the affected tissue (rare)
 Bronchoscopy
 Chest CT scan
 Chest x-ray
 Interferon-gamma release blood test such as the
QFT-Gold test to test for TB infection
 Sputum examination and cultures
 Thoracentesis
 Tuberculin skin test (also called a PPD test)

 QFT-Gold test is a rapid diagnostic test where
blood is obtained from the patient and placed in
chambers along with mycobacterial antigens. If the
patient is infected with tuberculosis organisms,
the lymphocytes in the blood will recognize these
antigens and secrete ᵞ-interferon, a cytokine
produced by lymphocytes.
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Tuberculin skin test:
A dose of 5 TU (tuberculin units) of PPD
(0.1 ml) is injected intra dermally and
after 48-72 hours the indurations
(swelling) is observed.
 If the swelling is <5mm – no TB
 If the swelling is >5mm – TB is present

 Bones. Spinal pain and joint destruction may
result from TB that infects your bones(TB spine or
pott’s spine)
 Brain(meningitis)
 Liver or kidneys
 Heart(cardiac tamponade)
 Pleural effusion
 Tb pneumonia
 Serious reactions to drug therapy(hepato
toxicity;hypersentivity)

 PULMONARY TB is treated primarily with
antituberculosis agents for 6 to 12 months.
Pharmacological management :
First line antitubercular medications
 ISONIAZID(H)
 RIFAMPICIN(R)
 PYRAZINAMIDE(Z)
 ETHAMBUTOL(E)
 STREPTOMYCIN(S).

 Isoniazid is the most active drug for the
treatment of tuberculosis caused by
susceptible strains.
 Mechanisms of action: Isoniazid inhibits
synthesis of mycolic acids, which are
essential components of mycobacterial cell
walls.
 DOSE: ADULTS: PO/IM 5 mg/kg/day as
single daily dose (max 300 mg/day).
INFANTS & CHILDREN: PO/IM 10 to 20
mg/kg/day in single daily dose (max 300
mg/day.

 Allergic Reaction: fever, skin rash
 Hepatotoxicity: Up to 20% of patients taking
INH develop elevated serum amino
transferase levels.
 Severe hepatic injury occurs more frequently
in patients over the age of 35, especially in
those who are alcoholic.
 Peripheral and CNS toxicity - toxicity results
from an increased excretion of pyridoxine
induced by ionized, which produces a
pyridoxine deficiency.
 Peripheral neuritis, urinary retention,
insomnia, and psychotic episodes can occur.

 Semi synthetic derivative of rifamycin,
an antibiotic obtained from
streptomyces mediterranei.
 Highly effective tuberculocidal
 Acts on both intra and extracellular
organisms.
 It is called a sterilizing agent.

Mechanisms of action:
It binds strongly to the β-subunit of DNA-
dependent RNA polymerase and thereby
inhibits RNA synthesis. It is bactericidal
for mycobacteria.
DOSES:
Rifampin, usually 600 mg/d (10 mg/kg/d)
orally, must be administered with
isoniazid or other antituberculous drugs
to patients with active tuberculosis to
prevent emergence of drug-resistant
mycobacteria.

 Urine, sweat, tears, and contact lenses may
take on an orange color because of rifampin
administration, this effect is harmless.
 Light-chain proteinuria and impaired antibody
response may occur.
 Rifampin induces hepatic microsomal
enzymes and therefore, affects the half-life of a
number of drugs.
 When taken erratically in large doses, a febrile
“flu-like” syndrome can occur.

 It is bacteriostatic for the tubercle
bacillus
 Well absorbed from the gut and widely
distributed in all body tissues and
fluids.
 Resistance to ethambutol emerges
rapidly when the drug is used alone.
 The most common serious adverse effect
is dose-related optic neuritis, causing
loss of visual acuity and red-green color-
blindness, but is reversible.

DOSES:
Ethambutol hydrochloride, 15–25
mg/kg, is usually given as a single
daily dose
50 mg/kg when a twice-weekly dosing
schedule

 Analog of nicotinamide
 Tuberculocidal
 Requires acidic pH for its activity.
 Quickly absorbed after oral
administration
 Widely distributed in body tissues,
including inflamed meninges.
 Excreted mainly by glomerular
filtration.

DOSE:
 40–50 mg/kg is used for thrice-weekly
or twice-weekly treatment regimens .
ADVERSE REACTION:
 Major adverse effects of pyrazinamide
include hepatotoxicity (in 1–5% of
patients)
 nausea, vomiting, drug fever, and
hyperuricemia.
 Hyperuricemia may provoke acute
gouty arthritis.

Streptomycin - first antimicrobial drug
used to treat tuberculosis.
It is effective against most tubercle
bacilli, but its activity is weaker than
that of INH and RFP.
Streptomycin penetrates cells poorly-
produce drug resistance.
It is always given together with other
drugs to prevent emergence of
resistance.

DOSES:
The typical adult dose is 1 g/d (15
mg/kg/d). If the creatinine clearance is
less than 30 mL/min or the patient is on
hemodialysis, the dose is 15 mg/kg two
or three times a week .

1. Amino glycosides: E.G., Amikacin
(Amk), Kanamycin (Km);
2. Polypeptides: E.G., Capreomycin,
Viomycin, Enviomycin;
3. Fluoroquinolones: E.G., Ciprofloxacin
(Cip), Levofloxacin, Moxifloxacin (Mxf);
4. Thioamides: E.G. Ethionamide,
Prothionamide
5. Cycloserine (The Only Antibiotic In Its
Class);
6. P-Aminosalicylic Acid(PAS or P).
35

 Kanamycin has been used for treatment of
TB caused by streptomycin-resistant
strains, but the availability of less toxic
alternatives (eg, capreomycin and
amikacin) has rendered it obsolete
 Serum concentrations of 30–50 mcg/mL
are achieved 30–60 minutes after a 15
mg/kg intravenous infusion
 Indication- treatment of tuberculosis
suspected or known to be caused by
streptomycin-resistant or multidrug-
resistant strains.
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 Peptide protein synthesis inhibitor,
antibiotic obtained from Streptomyces
capreolus.
 Daily injection of 1 g intramuscularly
 Capreomycin (15 mg/kg/d) is an
important injectable agent for treatment
of drug-resistant tuberculosis.
 Nephrotoxic and ototoxic,tinnitus,
deafness, and vestibular disturbances
occur.
 The injection causes significant local
pain, and sterile abscesses may occur
37

 Ciprofloxacin, levofloxacin, gatifloxacin,
and moxifloxacin inhibit strains of M
tuberculosis
 Moxifloxacin is the most active against
M tuberculosis by weight
 The drug must be used in combination
with two or more other active agents-to
prevent resistance
 Standard dosage of ciprofloxacin is 750
mg orally twice a day, levofloxacin is
500–750 mg once a day, moxifloxacin is
400 mg once a day

 Ethionamide is chemically related to
isoniazid
 Blocks the synthesis of mycolic acids
 Ethionamide is administered at an
initial dose of 250 mg once daily, which
is increased in 250-mg increments to
the recommended dosage of 1 g/d (or
15 mg/kg/d), if possible.
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I. Intense gastric irritation , neurologic
symptoms
II. Ethionamide is also hepatotoxic.
III. Neurologic symptoms may be
alleviated by pyridoxine
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 Cycloserine is an inhibitor of cell wall
synthesis.
 Cycloserine is cleared renally, and the
dose should be reduced by half if
creatinine clearance is less than 50
mL/min.
Route/Dosage:
 ADULTS: PO 250–500 mg q 12 hr; start
with 250 mg q 12 hr for first 2 wk
(maximum 1 g/day). CHILDREN: PO 10–
20 mg/kg/day administered in 2 equally
divided doses (maximum 1 g/day).

Contraindications-
 Epilepsy, depression, severe anxiety
or psychosis, severe renal
insufficiency, excessive concurrent use
of alcohol.
ADVERSE:
 Peripheral neuropathy and central
nervous system dysfunction,
depression and psychotic reactions.

These drugs are considered as third line
drugs since it is not very effective or
because their efficacy has not been
proven.
 Rifabutin
 Macrolides:e.g.,clarithromycin (CLR)
 Linezolid(LZD)
 Thioacetazone(T)
 Thioridazine
 Arginine
 Vitamin D
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 Inhibits DNA-dependent RNA
polymerase in susceptible strains of
bacteria
 Rifabutin is both substrate and inducer
of cytochrome P450 enzymes.
 it is a less potent inducer, rifabutin is
indicated in place of rifampin for
treatment of tuberculosis in HIV-
infected patients who are receiving
concurrent antiretroviral therapy with a
protease inhibitor or NNRTI (eg,
efavirenz)
44

DOTS (directly observed treatment, short-course), is
the name given to the World Health Organization-
recommended tuberculosis control strategy that
combines five components:
1. Government commitment (including both
political will at all levels, and establishing a
centralized and prioritized system of TB
monitoring, recording and training)
2. Case detection by sputum smear microscopy
45

3.Standardized treatment regimen directly observed by a
healthcare worker or community health worker for
at least the first two months
4.A regular drug supply.
5.A standardized recording and reporting system that
allows assessment of treatment results.
6. DOT is especially critical for patients with drug-
resistant TB, HIV-infected patients, and those
on intermittent treatment regimens (i.e., 2 or 3
times weekly).
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Assessment
Obtain history of exposure to TB
Assess for symptoms of active disease
Auscultate lungs for crackles
During drug therapy assess for liver
function

 Ineffective breathing pattern related to
pulmonary infection and potential for long
term scarring with decreased lung capacity
 Risk for spreading infection related to
nature of disease and patients symptoms
 Imbalanced nutrition less than body
requirement related to poor appetite ,fatique
and productive cough
 Non compliance related to lack of motivation
and lack of treatment.
49

 ISOLATION
 Ventilate the room
 Cover the mouth
 Wear mask
 Finish entire course of medication
 vaccinations
50

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