1. Copyright © 2006 by Mosby, Inc. Slide 1 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

2. Copyright © 2006 by Mosby, Inc. Slide 2 Anatomic Alterations of the Lungs (Three categories)  Primary tuberculosis  Primary infection stage  Postprimary tuberculosis  Secondary or reinfection TB  Disseminated tuberculosis  Extrapulmonary TB

3. Copyright © 2006 by Mosby, Inc. Slide 3 Anatomic Alterations of the Lungs (Mainly Primary TB)  Alveolar consolidation  Alveolar-capillary destruction  Caseous tubercles or granulomas  Fibrosis and secondary calcification of the lung parenchyma  Distortion and dilation of the bronchi  Increased bronchial airway secretions

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology  In human, TB primarily caused by Mycobacterium tuberculosis  Others  Mycobacterium bovis  Mycobacterium ulcerans  Mycobacterium kansasii  Mycobacterium avium-intracellulare  Highly aerobic organisms

5. Copyright © 2006 by Mosby, Inc. Slide 5 Diagnosis  Intradermal tuberculin skin testing  Mantoux test  Injection of purified protein derivative (PPD) Wheal <5 mm: negative Wheal <5 mm: negative Wheal 5 mm to 9 mm: considered suspicious Wheal 5 mm to 9 mm: considered suspicious Wheal 10 mm or greater: positive Wheal 10 mm or greater: positive

6. Copyright © 2006 by Mosby, Inc. Slide 6 Diagnosis  Acid-fast stain and sputum culture  Ziehl-Neelsen stain Reveals bright red acid-fast bacilli against a blue background Reveals bright red acid-fast bacilli against a blue background  Fluorescent acid-fast stain Reveals luminescent yellow-green bacilli against a dark brown background Reveals luminescent yellow-green bacilli against a dark brown background  A culture is necessary to differentiate M. tuberculosis form other acid-fast organisms Results take as long as 6 to 8 weeks Results take as long as 6 to 8 weeks

7. Copyright © 2006 by Mosby, Inc. Slide 7 Diagnosis  Identification of Mycobacterium species  Polymerase chain reaction (PCR) Quick identification of organisms in expectorated or bronchoscopically obtained sputum Quick identification of organisms in expectorated or bronchoscopically obtained sputum  Deoxyribonucleic acid (DNA) probe

8. Copyright © 2006 by Mosby, Inc. Slide 8 Nontuberculosis Mycobacteria  Mycobacterial infection caused by species other than M. tuberculosis are called nontuberculosis mycobacteria (NTM)—also called:  Mycobacteria other than tuberculosis (MOTT)  Atypical mycobacterial infection  Found in soil and water

9. Copyright © 2006 by Mosby, Inc. Slide 9 Overview of the Cardiopulmonary Clinical Manifestations Associated with TUBERCULOSIS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Alveolar Consolidation (see Figure 9-8), and Increased Alveolar-Capillary Membrane Thickness (see Figure 9-9)—the major anatomic alterations of the lungs associated with tuberculosis (see Figure 17-1).

10. Copyright © 2006 by Mosby, Inc. Slide 10 Figure 9-8. Alveolar consolidation clinical scenario.

11. Copyright © 2006 by Mosby, Inc. Slide 11 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

12. Copyright © 2006 by Mosby, Inc. Slide 12 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

13. Copyright © 2006 by Mosby, Inc. Slide 13 Clinical Data Obtained at the Patient’s Bedside  Chest pain/decreased chest expansion  Cyanosis  Digital clubbing  Peripheral edema and distention  Distended neck veins  Pitting edema  Enlarged and tender liver

14. Copyright © 2006 by Mosby, Inc. Slide 14 Digital Clubbing Figure 2-46. Digital clubbing.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

16. Copyright © 2006 by Mosby, Inc. Slide 16 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Clinical Data Obtained at the Patient’s Bedside  Cough, sputum production, and hemoptysis  Chest assessment findings  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Crackles, rhonchi, and wheezing  Pleural friction rub  Whispered pectoriloquy

18. Copyright © 2006 by Mosby, Inc. Slide 18 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

20. Copyright © 2006 by Mosby, Inc. Slide 20 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

21. Copyright © 2006 by Mosby, Inc. Slide 21 Clinical Data Obtained from Laboratory Tests and Special Procedures

22. Copyright © 2006 by Mosby, Inc. Slide 22 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

23. Copyright © 2006 by Mosby, Inc. Slide 23 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or     VC IC ERV RV/TLC%    N V T RV FRC TLC N or     VC IC ERV RV/TLC%    N

24. Copyright © 2006 by Mosby, Inc. Slide 24 Arterial Blood Gases Mild to Moderate Tuberculosis  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. PaO 2 and PaC0 2 trends during acute alveolar hyperventilation.

26. Copyright © 2006 by Mosby, Inc. Slide 26 Arterial Blood Gases Extensive Tuberculosis with Pulmonary Fibrosis  Chronic ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2 Normal   (Significantly)  pH PaCO 2 HCO 3 - PaO 2 Normal   (Significantly) 

27. Copyright © 2006 by Mosby, Inc. Slide 27 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Chronic Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

28. Copyright © 2006 by Mosby, Inc. Slide 28 Acute Ventilatory Changes on Chronic Ventilatory Failure  Acute alveolar hyperventilation on chronic ventilatory failure  Acute ventilatory failure on chronic ventilatory failure

29. Copyright © 2006 by Mosby, Inc. Slide 29 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2  

30. Copyright © 2006 by Mosby, Inc. Slide 30 Hemodynamic Indices (Severe Tuberculosis) CVP RAPPAPCWP  Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR  Normal  Normal

31. Copyright © 2006 by Mosby, Inc. Slide 31 Abnormal Laboratory Tests and Procedures  Positive tuberculosis skin test (PPD)  Positive acid-fast bacillus stain of sputum and sputum culture

32. Copyright © 2006 by Mosby, Inc. Slide 32 Radiologic Findings Chest radiograph  Increased opacity  Ghon’s complex  Cavity formation  Pleural effusion  Calcification and fibrosis  Retraction of lung segments or lobe  Right ventricular enlargement

33. Copyright © 2006 by Mosby, Inc. Slide 33 Figure 17-2. Cavitary reactivation TB showing a left upper lobe cavity and localized pleural thickening (arrows). (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

34. Copyright © 2006 by Mosby, Inc. Slide 34 General Management of Tuberculosis Pharmacologic agents  Consists of 2 to 4 drugs for 6 to 12 months  First-line agents (first 9 months) Isoniazid (INH) and rifampin (Rifadin) Isoniazid (INH) and rifampin (Rifadin) INH most effective INH most effective  Often supplemented with: Ethambutol Ethambutol Streptomycin Streptomycin Pyrazinamide Pyrazinamide

35. Copyright © 2006 by Mosby, Inc. Slide 35 General Management of Tuberculosis  Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Mechanical ventilation protocol

36. Copyright © 2006 by Mosby, Inc. Slide 36 Review  The protective cell wall that surrounds and encases the TB bacilli is called -?  Tubercle or granuloma  What is primary TB?  Reaction following first exposure to pathogen Inflammation leading to alveolar consolidation Inflammation leading to alveolar consolidation Formation of tubercle Formation of tubercle Fibrosis and calcification, development of bronchiectasis Fibrosis and calcification, development of bronchiectasis

37. Copyright © 2006 by Mosby, Inc. Slide 37  What is postprimary TB?  Reactivation of TB after initial infection has been controlled  What is dissemminated TB?  Infection that spreads to sites outside the lung via pulmonary lymphatic system or bloodstream  The presence of numerous small tubercles scattered throughout the body is called - ?  Miliary tuberculosis

38. Copyright © 2006 by Mosby, Inc. Slide 38  How long can TB bacillus remain suspended in the air after a sneeze or a cough?  Several hours  What is a Ghon’s complex?  Combination of tubercles and hilar lymphadenopathy seen on CXR  Typical ABG’s from a patient with extensive TB and fibrosis would be describe as - ?  Chronic Ventilatory failure and hypoxemia

39. Copyright © 2006 by Mosby, Inc. Slide 39  What hemodynamic indices reflect right-side heart failure in a patient with advanced TB?  Increased CVP  Increased RAP  Increased mean PA  Increased PVR  Increased RVSWI  What respiratory care treatments/protocols are used for TB?  O2 Therapy  BHT  Hyperinflation Therapy

40. Copyright © 2006 by Mosby, Inc. Slide 40 True or False  Pleural space complications such as empyema and pneumothorax are common in patients with tuberculosis.  True  A positive reaction to the tuberculin skin test confirms that a patient has active tuberculosis  False  Tuberculosis commonly develops in the apices of the lungs  True

41. Copyright © 2006 by Mosby, Inc. Slide 41 Classroom Discussion Case Study: Tuberculosis