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Chapter 17

Tuberculosis


Figure 17-1. Tuberculosis. A, Early primary infection. B, Cavitation of a caseous tubercle and new primary lesions developing. C, Further progression and development of cavitations and new primary infections. Note

the subpleural location of some of these lesions. D, Severe lung destruction caused by tuberculosis.

A

C

B

D


Anatomic Alterations of the Lungs

Tuberculosis is classified as either: Primary tuberculosis—also called:

Primary infection stage

Postprimary tuberculosis—also called:

Reactivation TB

Reinfection TB

Secondary TB

Disseminated tuberculosis—also called:

Extrapulmonary TB

Miliary TB

Tuberculosis-disseminated


Anatomic Alterations of the Lungs

(Mainly Postprimary TB)

Alveolar consolidation

Alveolar-capillary destruction

Caseous tubercles or granulomas

Cavity formation

Fibrosis and secondary calcification of the

lung parenchyma

Distortion and dilation of the bronchi

Increased bronchial airway secretions


Etiology

In humans, TB primarily caused by

Mycobacterium tuberculosis

Highly aerobic organisms

Bacilli are acid-fast bacilli

The bacilli are almost exclusively transmitted

within aerosol droplets produced by

coughing, sneezing, or laughing of an

individual with active TB.


Diagnosis

Mantoux tuberculin skin test

Acid-fast Staining

Sputum Culture

QuantiFERON®-TB Gold Test


Diagnosis (Cont’d)

Mantoux tuberculin skin test Injection of purified protein derivative (PPD)

• Wheal less than 5 mm: negative

• Wheal 5 mm to 9 mm: considered suspicious

• Wheal 10 mm or greater: positive


Figure 17-2. The Mantoux test, which consists of an intradermal injection of a small amount of a purified protein derivative (PPD) of the tuberculin bacillus. An induration of 10 mm or greater is

considered positive. A positive reaction is fairly sound evidence of recent or past infection or disease.


Acid-fast stain and sputum culture Ziehl-Neelsen stain

• Reveals bright red acid-fast bacilli against a blue

background

Fluorescent acid-fast stain• Reveals luminescent yellow-green bacilli against a dark

brown background



Sputum Culture Because a variety of nontuberculous strains of

Mycobacterium can show up on an AFB smear, a sputum

culture is often necessary to differentiate M. tuberculosis

from other acid-fast organisms.

For example, common nontuberculous acid-fast

mycobacteria associated with COPD are Mycobacterium

avium and Mycobacterium kansasii.

Sputum cultures can also identify drug-resistant bacilli and

their sensitivity to antibiotic therapy. M. tuberculosis grows

very slowly.

It takes up to 6 weeks for colonies to appear in culture.



QuantiFERON-TB Gold Test In 2005, the U.S. Food and Drug Administration

(FDA) approved the QuantiFERON-TB Gold test

(QFT-G).

The QFT-G is a whole-blood test used for

diagnosing Mycobacterium tuberculosis infection,

including latent tuberculosis infection.

Results are available after 24 hours



Overview

of the Cardiopulmonary Clinical Manifestations

Associated with

Tuberculosis

The following clinical manifestations result from the

pathophysiologic mechanisms caused (or activated)

by Alveolar Consolidation

Increased Alveolar-Capillary Membrane Thickness




Clinical Data Obtained at the

Patient’s Bedside


The Physical Examination

Vital Signs Increased

• Respiratory rate (Tachypnea)

• Heart rate (pulse)

• Blood pressure


The Physical Examination (Cont’d)

Chest pain/decreased chest expansion

Cyanosis

Digital clubbing

Peripheral edema and venous distention Distended neck veins

Pitting edema

Enlarged and tender liver

Cough, sputum production, and hemoptysis


The Physical Examination (Cont’d)

Chest Assessment Findings

Increased tactile and vocal fremitus

Dull percussion note

Bronchial breath sounds

Crackles, rhonchi, and wheezing

Pleural friction rub • if process extends to pleural surface

Whispered pectoriloquy


Clinical Data Obtained from

Laboratory Tests and Special

Procedures


Pulmonary Function Test FindingsModerate and Extensive Cases

(Restrictive Lung Pathophysiology)

Forced Expiratory Flow Rate Findings

FVC FEVT FEV1/FVC ratio FEF25%-75

N or N or N or

FEF50% FEF200-1200 PEFR MVV

N or N or N or N or


Pulmonary Function Test Findings Moderate and Extensive Cases

(Restrictive Lung Pathophysiology)

Lung Volume & Capacity Findings

VT IRV ERV RV VC

N or

IC FRC TLC RV/TLC ratio

N


Arterial Blood GasesModerate Tuberculosis

Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)

pH PaC02 HCO3 Pa02

(slightly)


PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesExtensive Tubeculosis with Pulmonary Fibrosis

Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis)

pH PaC02 HCO3 Pa02

N (Slightly)


PaO2 and PaCO2 trends during acute or chronic ventilatory failure.


Arterial Blood Gases

Acute Ventilatory Changes Superimposed

On

Chronic Ventilatory Failure

Because acute ventilatory changes are frequently seen in

patients with chronic ventilatory failure, the respiratory

care practitioner must be familiar with and alert for the

following: Acute alveolar hyperventilation superimposed on chronic

ventilatory failure

Acute ventilatory failure (acute hypoventilation) superimposed on

chronic ventialtory failure.


Oxygenation IndicesModerate to Severe Stages

QS/QT D02 V02 C(a-v)02 02ER Sv02

N N


Hemodynamic IndicesSevere Stage

CVP RAP PA PCWP CO SV

N N N

SVI CI RVSWI LVSWI PVR SVR

N N N N


Abnormal Laboratory Tests and

Procedures

Positive tuberculosis skin test (PPD)

Positive sputum acid-fast bacillus (AFB) stain test

Positive sputum culture


Radiologic Findings

Chest Radiograph Increased opacity

Ghon nodule

Ghon complex

Cavity formation

Cavity lesion containing an air-fluid level (see Figure 16-2)

Pleural effusion

Calcification and fibrosis

Retraction of lung segments or lobe

Right ventricular enlargement


Figure 17-5. Cavitary reactivation tuberculosis showing a left upper lobe cavity and localized pleural

thickening (arrows). (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of

the chest, ed 4, Philadelphia, 2005, Elsevier.)


Figure 17-6. Miliary tuberculosis showing widespread uniformly distributed fine nodulation of the lung.


General Management of

Tuberculosis

Pharmacologic agents

Consists of 2 to 4 drugs for 6 to 9 months 6-month treatment protocol:

• For the first 2 months (call the induction phase), the

patient takes a daily dose of isoniazid (INH), rifampin,

pyrazinamide, and either ethambutol or streptomycin.

• For the next 4 months, the patient takes isoniazid and

rifampin daily or twice weekly.



Tuberculosis (Cont’d)

9-month treatment protocol: • For the first 1 to 2 months, the patient takes a daily dose

of isoniazid and rifampin,

• followed by twice-weekly isoniazid and rifampin until the

full 9 month period is completed.


Isoniazid (INH) and rifampin (Rifadin) are first-line

agents prescribed for the entire 9 months.

Isoniazid is considered to be the most effective

first-line antituberculosis agent.

Rifampin is bactericidal and is most commonly

used with isoniazid.


Tuberculosis (Cont’d)


Respiratory Care Treatment

Protocols

Oxygen Therapy Protocol

Bronchopulmonary Hygiene Therapy Protocol

Mechanical Ventilation Protocol

Documents

Chapter 7 Body Systems - media.lanecc.edumedia.lanecc.edu/users/driscolln/RT136/powerpoint_pdfs/DJ_Chapter... · Chapter 17 Tuberculosis. ... Pulmonary Function Test Findings Moderate