Adult Medical-Surgical Adult Medical-Surgical NursingNursing

Respiratory Module: Respiratory Module:

TuberculosisTuberculosis

Tuberculosis (TB):Tuberculosis (TB):DescriptionDescription

Tuberculosis is a chronic infectious Tuberculosis is a chronic infectious disease primarily of the lungs (but may disease primarily of the lungs (but may spread elsewhere through blood/ lymph)spread elsewhere through blood/ lymph)

Caused by Mycobacterium Tuberculosis, Caused by Mycobacterium Tuberculosis, an acid-fast bacillusan acid-fast bacillus

Spread by droplet infection: very infectious Spread by droplet infection: very infectious in close communitiesin close communities

Tuberculosis: Tuberculosis: Epidemiology/ Incidence Epidemiology/ Incidence

TB is TB is thethe leading cause of death from leading cause of death from infectious disease world-wideinfectious disease world-wideAssociated with poverty, malnutrition, Associated with poverty, malnutrition, overcrowding, poor health care, HIVovercrowding, poor health care, HIVA historical decline of TB occurred in C20 A historical decline of TB occurred in C20 in some areas with ↑ housing, sanitation in some areas with ↑ housing, sanitation nutrition (↑ immunity) and later antibioticsnutrition (↑ immunity) and later antibioticsNow increased incidence, associated with Now increased incidence, associated with migration, migration, HIVHIV, multi-drug resistance, multi-drug resistance

Tuberculosis: Tuberculosis: PathophysiologyPathophysiology

TB bacilli are inhaled and start to multiply TB bacilli are inhaled and start to multiply in the alveoliin the alveoli

Inflammatory/ immune response occurs Inflammatory/ immune response occurs (2-10 weeks post-exposure): (2-10 weeks post-exposure):

Exudate accumulates in the alveoli Exudate accumulates in the alveoli (bronchopneumonia) →(bronchopneumonia) →

Tuberculosis: Tuberculosis: Pathophysiology Pathophysiology

Disease progression leads to formation of Disease progression leads to formation of granulomasgranulomas in the alveoli (live and dead in the alveoli (live and dead bacilli surrounded by macrophages) →bacilli surrounded by macrophages) →

Granulomas fibrose surrounding a necrotic Granulomas fibrose surrounding a necrotic centre: “Ghon Tubercles” → centre: “Ghon Tubercles” →

Calcification = dormant state Calcification = dormant state (no longer active disease) (no longer active disease)

Tuberculosis: Tuberculosis: ReinfectionReinfection

If while TB is dormant patient immunity If while TB is dormant patient immunity becomes low: becomes low: Reinfection/ re-activation occurs from the Reinfection/ re-activation occurs from the dormant state → dormant state → Active diseaseActive diseaseThe Ghon Tubercles ulcerate, releasing The Ghon Tubercles ulcerate, releasing the cheesy material with live bacilli into the the cheesy material with live bacilli into the bronchibronchiBacilli are airborne and spread the diseaseBacilli are airborne and spread the disease

Tuberculosis: Tuberculosis: Progression of the diseaseProgression of the disease

TB is a chronic respiratory disease with:TB is a chronic respiratory disease with:Slow progression in the lungSlow progression in the lungLong remission periods Long remission periods Untreated disease spreads to other organs Untreated disease spreads to other organs via the blood and lymph (kidneys, bone, via the blood and lymph (kidneys, bone, brain)brain)Prolonged intensive treatment required to Prolonged intensive treatment required to eradicate the bacillieradicate the bacilliHealth/ immune response affects progressHealth/ immune response affects progress

Tuberculosis: Tuberculosis: Clinical ManifestationsClinical Manifestations

Insidious onsetInsidious onsetLow grade feverLow grade feverCough: Cough: Non-productive, mucopurulent or Non-productive, mucopurulent or haemoptysis - “rusty”haemoptysis - “rusty”Night sweatsNight sweatsFatigueFatigueWeight lossWeight loss

Tuberculosis: DiagnosisTuberculosis: Diagnosis

Chest Xray (AP/ lateral)Chest Xray (AP/ lateral)Sputum for Acid-Fast Bacilli (AFB)Sputum for Acid-Fast Bacilli (AFB)Mantoux (PPD) tuberculin skin test: Mantoux (PPD) tuberculin skin test: wheel/flare reaction read at 48-72 hours (if wheel/flare reaction read at 48-72 hours (if immunosuppressed may be no reaction)immunosuppressed may be no reaction)QuantiFERON-TB Gold Test: enzyme-QuantiFERON-TB Gold Test: enzyme-linked immunosorbent assay (ELISA) linked immunosorbent assay (ELISA) blood test to detect interferon-gamma blood test to detect interferon-gamma released from white blood cells in TBreleased from white blood cells in TB

Tuberculosis: DiagnosisTuberculosis: Diagnosis

To monitor spread of disease outside the To monitor spread of disease outside the lungs:lungs:

Skeletal Xray Skeletal Xray

Early morning urine samples for AFB Early morning urine samples for AFB

Tuberculosis: ManagementTuberculosis: Management

Notification to the Ministry of HealthNotification to the Ministry of Health

Immediate follow-up and screening of Immediate follow-up and screening of allall contacts (given prophylactic treatment)contacts (given prophylactic treatment)

If active TB, respiratory isolation until If active TB, respiratory isolation until remission (usually non-infectious after remission (usually non-infectious after 2-3 weeks of continuous therapy)2-3 weeks of continuous therapy)

Intensive antibiotic therapy over 6-12 Intensive antibiotic therapy over 6-12 months to prevent relapse months to prevent relapse

Tuberculosis: Antibiotic TherapyTuberculosis: Antibiotic Therapy

Anti-TB antibiotic drugs are:Anti-TB antibiotic drugs are:

RifampicinRifampicin

PyrazinamidePyrazinamide

Isoniazid (INH)Isoniazid (INH)

Streptomycin Streptomycin

EthambutolEthambutol

Tuberculosis: Tuberculosis: Antibiotic Treatment RegimeAntibiotic Treatment Regime

AtAt leastleast 4 4 drugs used intensively for the drugs used intensively for the first 8 weeksfirst 8 weeksIf sputum culture is sensitive to the drugs:If sputum culture is sensitive to the drugs:Treatment with Treatment with 33 drugs for further 8 weeks drugs for further 8 weeks (stop Streptomycin or Ethambucil)(stop Streptomycin or Ethambucil)Isoniazid (INH) and Rifampicin therapy for Isoniazid (INH) and Rifampicin therapy for further 4-8 months (total 8-12 months)further 4-8 months (total 8-12 months)Vitamin B6 taken with INH to avoid Vitamin B6 taken with INH to avoid neuropathyneuropathy

Tuberculosis:Tuberculosis:Nursing ConsiderationsNursing Considerations

Follow-up screening of all contactsFollow-up screening of all contactsPatient and family education:Patient and family education:The importance of The importance of strictstrict adherence to adherence to medication (* if not taken regularly medication (* if not taken regularly resistance develops*) resistance develops*) Avoidance of spread of disease (isolation): Avoidance of spread of disease (isolation): health education health educationImportance of good nutrition, hygiene, Importance of good nutrition, hygiene, adequate housing in improving immunity adequate housing in improving immunity

Tuberculosis: Follow-up/Tuberculosis: Follow-up/Monitoring ProgressMonitoring Progress

Monitor progress through:Monitor progress through:

Vital signs (spiking temperature)Vital signs (spiking temperature)

Night sweatsNight sweats

Weight (gain/ loss)Weight (gain/ loss)

Regular chest XraysRegular chest Xrays

Sputum samplesSputum samples

Monitor for drug side-effectsMonitor for drug side-effects