1. 1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 17 Tuberculosis

2. 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

3. 3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

4. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

5. 5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

6. 6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnosis   Mantoux tuberculin skin test   Acid-fast Staining   Sputum Culture   QuantiFERON®-TB Gold Test

7. 7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

8. 8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

9. 9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   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 Diagnosis (Cont’d)

10. 10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  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. Diagnosis (Cont’d)

11. 11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   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 Diagnosis (Cont’d)

12. 12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

13. 13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

14. 14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained at the Patient’s Bedside

16. 16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination   Vital Signs  Increased Respiratory rate (Tachypnea) Heart rate (pulse) Blood pressure

17. 17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

18. 18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

19. 19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

20. 20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate and Extensive Cases (Restrictive Lung Pathophysiology) Forced Expiratory Flow Rate Findings FVC FEV T FEV 1 /FVC ratio FEF 25%-75  N or  N or  N or  FEF 50% FEF 200-1200 PEFR MVV N or  N or 

21. 21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

22. 22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Moderate Tuberculosis Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaC0 2 HCO 3 Pa0 2    (slightly) 

23. 23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

24. 24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Extensive Tubeculosis with Pulmonary Fibrosis Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis) pH PaC0 2 HCO 3 Pa0 2 N   (Slightly) 

25. 25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

26. 26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

27. 27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices Moderate to Severe Stages Q S /Q T D02 V02 C(a-v)02 02ER Sv02   N N  

28. 28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Severe Stage CVP RAP PA PCWP CO SV    N N N SVI CI RVSWI LVSWI PVR SVR N N  N  N

29. 29 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Laboratory Tests and Procedures  Positive tuberculosis skin test (PPD)  Positive sputum acid-fast bacillus (AFB) stain test  Positive sputum culture

30. 30 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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

31. 31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 17-5. Cavitary reactivation tuberculosis showing a left upper lobe cavity and localized pleural thickening (arrows). 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.)

32. 32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 17-6. Miliary tuberculosis showing widespread uniformly distributed fine nodulation of the lung.

33. 33 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

34. 34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. General Management of 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.

35. 35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   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. General Management of Tuberculosis (Cont’d)

36. 36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Treatment Protocols   Oxygen Therapy Protocol   Bronchopulmonary Hygiene Therapy Protocol   Mechanical Ventilation Protocol