ptb revised

PTBPTB

Pulmonary Tuberculosis

DefinitionDefinition

DefinitionDefinition

Tubercle

• Caseation

• Necrosis

• Fibrosis

• Calcification

Spread on tissues

• Spread through bronchi/bronchioles

•Dissemination through blood or lymph channels

2 – 10 weeks

From the first entry until the appearance of

the first signs & symptoms

Incubation period

Etiology

overcrowded homes Malnutrition Deficiencies in 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 Tuberculosisa. 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

Visibly ill 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

Finding the acid-fast bacilli in the sputum obtained by coughing & expectoration

Culture are 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

Treatment

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

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

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

Category Type of TB patient

Treatment of Regimen

Intensive Phase

Continuation Phase

I

New smear-positive PTB New smear-negative PTB with extensive

parenchymal lessions on CXR as assessed by the TBDC

EPTB Severe concomitant HIV disease

2HRZE 4 HR

II

Treatment failure Relapse Return after default Other

2HRZE/ 1HRZE 5HRZE

III

New smear-negative PTB w/ minimal parenchymal lessions on CXR as assessed by the TBDC

2HRZE 4HR

IV

Chronic (still smear-positive after supervised re-treatment)

Refer to specialized facility or DOTS plus center

Refer to Provincial/City NTP Coordinator

Dosage per Category of Treatment Regimen

2. Specific chemotherapy

BW (kg)

No. of tablets/day

Intensive Phase

(2 mos.)

FDC – A (HRZE)

No. of tablets/day

Continuous Phase

(4 mos.)

FDC – B (HR)

30 37

2 2

38 -54

3 3

55 - 70

4 4

> 70

5 5

FDC : Categories I & III

FDC : Categories II: 2HRZES/HRZE/4HRE

BW (kg) Intensive Phase Continuation Phase

1st two mos 3rd month

FDC-B

(HR)

E

400 mgFDC-A

(HRZE)

Streptomycin FDC-A

(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

Intensive phase

(2 months)

No. of Tablets a day

Continuation Phase

(4 months)

Isoniazid (H) 1 1

Rifampicin (R) 1 1

Pyrazinamide (Z) 2

Ethambutol (E) 2

SDF: Categories II: 2HRZES/1HRZE/5HRE

Anti-TB drugs

No. of Tablets a day

Intensive phase

(3 months)

No. of Tablets a day

Continuation Phase

(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 BWDrug 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

PPrreevveennttiioonn

End of

presentation