You are on page 1of 47

PTB

Pulmonary Tuberculosis
Definition
Definition

• Caseation • Spread through


• Necrosis bronchi/bronchioles
Tubercle Spread on
• Fibrosis tissues • Dissemination
through blood or
• Calcification lymph channels
Incubation period

2 – 10 weeks

 From the first entry until the appearance of


the first signs & symptoms
Etiology

 overcrowded homes
 Malnutrition
 Deficienciesin Vitamin A, D, C
 Inadequate levels of immunity
 Alcoholism & smoking
Mode of Transmission
Risk Factors

 Close contact with someone who has active TB


 Immunocompromised status
 Preexisting medical conditions
 Living in overcrowded or substandard housing
 Significant reaction to tuberculin skin test
Clinical
Manifestations
Clinical Manifestations

1. Primary Infection
2. Postprimary/Progressive Primary
Tuberculosis
3. Chronic Pulmonary Tuberculosis
a. Generalized Systemic Signs
b. Pulmonary Signs & Symptoms
1. Primary Infection

 Change of behavior from normal to


listlessness
 Easy fatigability
 Alertness to apathy
 From normal activity to irritability
 Fleeting infection of respiratory/GIT
associated w/ fever
 Crepitant rales
2. Postprimary/Progressive Primary
Tuberculosis

 Visiblyill due to fever


 Cough gradually becomes distressing
 Abnormal physical signs are easily elicited
 Breath sounds increased (audible crepitant rales)
 Hemotysis is rare
3. Chronic Pulmonary Tuberculosis
a. Generalized Systemic Signs

 General malaise, anorexia, easy fatigability, apathy,


irritability, indigestion, general influenza-like
symptoms
 Physcal signs are meager
- tachycardia, low BP, dyspnea, cyanosis
 Afternoon fever (38oC – 39oC)
 Night sweat
 Loss of weight
 Malaise
3. Chronic Pulmonary Tuberculosis
b. Pulmonary Signs & Symptoms

 Insidious onset of cough with mucopurulent


sputum
 Fine crepitant rales over apical areas
 Hemoptysis & chest pain
 Pleural pain
 Dyspnea
Methods of
Physical
Examination
Methods of PE

 Inspection
- depression of the hemothorax on one side
- one or both clavicles may be prominent

 Palpation
- tactile fremitus

 Auscultation
- often advanced lesions give little or no
evidence of altered breathing
Diagnostic
Examination
Diagnostic Examinations

1. Chest x-ray
2. Sputum, smear, & culture
3. Tuberculin Test
2. Sputum, smear, & culture

 Findingthe acid-fast bacilli in the sputum


obtained by coughing & expectoration

 Cultureare helpful to determine bacterial


susceptibility to anti-TB drugs

 Purulent material should be cultured


3. Tuberculin skin test

 Tubercle bacillus & purified protein derivative


 Inject (Intradermal) at the inner forearm 4
inches below the elbow
 Result : 48 – 72 hours after injection
 Measure diameter of induration in mm
3. Tuberculin skin test
Interpretation of results

 0 – 4 mm : not significant
 > 5 mm : significant to those who are at risk
: due to cross reaction to other
mycobacterial infections
: due to incompletely developed
sensitivity

 > 10 mm : significant to those who have


normal/mildly impaired immunity
: positive reaction
Treatmen
t
Treatment

1. Prophylaxis
2. Specific chemotherapy
3. Surgical Management
1. Prophylaxis

a. BCG (Bacilli Calmette Guerin)

– simplest, safest, most economical, & most


effective measure of prevention

– Administered during neonateal period & repeated


before primary school

– Given at a dose of 0.05 – 0.1 ml intradermally


over the deltoid muscle
1. Prophylaxis
b. Primary Chemoprophylaxis
– Administration of Isoniazid (INH) to uninfected
subjects

– Administer INH instituted 8 wks after BCG


vaccination in groups with high risk infection

– Recommended daily : 5 mg/kg of body weight


given in single dose
1. Prophylaxis
c. Secondary Chemoprophylaxis
– Progression of primary lesions can be prevented
w/ INH w/ a daily dose of 5 – 10 mg/kg of body
weight

– Administered to patients with:


– Measles
– Pertusis
– Influenza
– Intake of steroids & immunosuppressive
– After surgery under general anesthesia
2. Specific chemotherapy

a. Isoniazid (INH) oral

– Duration: at least 1 yr

– For curative purposes, should be combined with


another drug to delay drug resistance

– Adverse reaction: cephalopathy hepatitis


2. Specific chemotherapy

b. Rifampicin (RMP) – oral

– Duration: 6 months

– Has antimycobacterial activity & most effective


anti-TB drug discovery of INH

– Adverse reaction: hypersensitivity &


hepatotoxicity
2. Specific chemotherapy

c. Ethambutol (EMB) - oral

– Duration: 3 months for initial treatment

– Dosage should be adjusted in patients w/


decreased renal function

– Adverse reaction: retinal degeneration


2. Specific chemotherapy

d. Streptomycin (SM) - IM

– Duration: 3 months – in most cases

– Skin test before administration

– Should not be given as the sole agent because


bacterial resistance develops more rapidly

– Adverse reaction: nephrotoxicity, vertigo, ataxia


2. Specific chemotherapy

e. Morphozinamide Hydrochloride (MZA) - oral

– Duration: with INH

– Pyrazinamide derivative

– Very effective anti-TB drug especially in caseous


forms of TB

– Adverse reaction: Hepatitis


2. Specific chemotherapy

f. Para-aminosalicylic Acid (PAS) - oral

– Duration: with INH

– Weakest among anti-TB drug

– Delays the emergence of resistant strains of tubercle


bacilli

– Adverse reaction: gastric iritation


2. Specific chemotherapy

 Fixed dose combination (FDC)


– 2 or more first-line anti-TB drugs are combined in
1 tablet

 Single drug formulation (SDF)


– Each drug is prepared individually
– Tablet: INH, Ethambutol, pyrazinamide
– Capsule: Rifampicin
2. Specific chemotherapy
Treatment of Regimen
Category Type of TB patient Intensive Phase Continuation
Phase
 New smear-positive PTB
I  New smear-negative PTB with extensive
parenchymal lessions on CXR as assessed
by the TBDC 2HRZE 4 HR
 EPTB
 Severe concomitant HIV disease

 Treatment failure
 Relapse
II  Return after default 2HRZE/ 1HRZE 5HRZE
 Other

 New smear-negative PTB w/ minimal


III parenchymal lessions on CXR as 2HRZE 4HR
assessed by the TBDC
Chronic (still smear-positive after supervised Refer to specialized facility or DOTS
IV re-treatment) plus center
Refer to Provincial/City NTP
Coordinator
2. Specific chemotherapy

Dosage per Category of


Treatment Regimen
FDC : Categories I & III
No. of tablets/day No. of tablets/day
BW (kg) Intensive Phase Continuous Phase
(2 mos.) (4 mos.)
FDC – A (HRZE) FDC – B (HR)
2 2
30 37
3 3
38 -54
4 4
55 - 70
5 5
> 70
FDC : Categories II: 2HRZES/HRZE/4HRE
BW (kg) Intensive Phase Continuation Phase

1st two mos 3rd month


FDC-B E
FDC-A Streptomycin FDC-A (HR) 400 mg
(HRZE) (HRZE)
30 – 37 2 0.75 g 2 2 1

38 – 54 3 0.75 g 3 3 2

55 -70 4 0.75 g 4 4 3

> 70 5 0.75 g 5 5 3
SDF: Categories I &II: 2HRZE/4HR

Anti-TB drugs No. of Tablets a day No. of Tablets a day


Intensive phase Continuation Phase
(2 months) (4 months)
Isoniazid (H) 1 1

Rifampicin (R) 1 1

Pyrazinamide (Z) 2

Ethambutol (E) 2
SDF: Categories II: 2HRZES/1HRZE/5HRE
No. of Tablets a day No. of Tablets a day
Intensive phase Continuation Phase
Anti-TB drugs (3 months) (5 months)

1st 2 months 3rd month

Isoniazid (H) 1 1 1

Rifampicin (R) 1 1 1

Pyrazinamide (Z) 2 2

Ethambutol (E) 2 2 2

Streptomycin 1 vial/day
Drug Dosage per Kg BW
Drug Dosage per kg BW in maximum dose

Isoniazid (H) 5 (4-6) mg/kg, & not to exceed 400mg/day

Rifampicin (R) 10 (8-12) mg/kg not to exceed 600 mg

Pyrazinamide (Z) 25 (20-30) mg/kg not to exceed 2 g

Ethambutol (E) 15 (15-20) mg/kg not to exceed 1.2 g

Streptomycin 15 (12-18) mg/kg not to exceed 1 g


Treatment Failures

 Use of substandard dosages


 Irregularity in taking the drugs
 Inadequate drug regimen
 The premature discontinuation of therapy
 The presence of drug resistance infections at
the start of the treatment
3. Surgical Management

 Pneumonectomy
 Indications: bronchiectasis, tuberculoma,
cavitary lesions, pulmonary cirhosis,
atolectasis
 Contraindication: active parenchymal lesions
& endobronchial tuberculosis
DOTS
Strategies
Nursing
Management
 Maintain respiratory isolation until pt responds to
treatment or no longer contagious
 Administer medicines as ordered
 Check sputum always for blood
 Encourage questions, conversation, to air their
feelings
 Teach or educate patient
 Encourage to stop smoking
 Teach patient to cough/sneeze into tissue
paper & dispose secretions properly
 Advise patient to have plenty of rest & eat
balance diet
 Be alert on signs of drug reaction
P
r
e
v
e
n
t
i
o
n
End
of
presentation