ptb revised
TRANSCRIPT
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