Pulmonary tuberculosis The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily attacks the lungs. However, it can spread from there to other organs. New treatment regimen is mentioned here.

1. PULMONARY
TUBERCULOSIS
Presented by:
Sonam

2. INTRODUCTION
Tuberculosis is a worldwide, chronic communicable
bacterial disease.
Tuberculosis disease is the outcome of the fight
between virulence of the organism and resistance of
the body.
Tuberculosis (TB) is an infectious disease that
primarily affects the lung parenchyma.

3. TYPES OF TUBERCULOSIS
1)Pulmonary tuberculosis
2)Extrapulmonary tuberculosis:
 Tuberculosis meningitis
 Renal and urogenital tuberculosis
 Bone and joint tuberculosis
 Tuberculosis enteritis
 Miliary tuberculosis
 Tuberculosis pleural effusion

5. EPIDEMIOLOGY
• According to WHO, India is the
country with highest burden of TB.
In 2016, about 2.79 million cases of
TB were reported in India out of the
total incidence of 10.4 million cases
globally.
• It kills more than 300,000 people in
India every year.
• 2 out of every 5 Indians are infected
with the TB bacillus

7. Contd…..
• The estimated TB incidence in India is 27 lakhs. It kills more than
300,000 people in India every year. In 2018, RNTCP was able to
achieve a notification of 21.5 lakh. This is a 16% increase as
compared to 2017 and the highest so far.
• The population largely remain similar with majority of the affected
individuals being in the age group of 15-69 years and 2/3rd being
males. HIV co-infection among TB was nearly fifty thousand cases
amounting to TB HIV coinfection rate of 3.4%.

8. AGENT
Mycobacterium tuberculosis
Koch’s bacillus
Acid fast bacillus

10. SOURCES OF INFECTION
• Human source
• Bovine source

11. HOST FACTORS
Age:
for age group 0-14 yrs: prevalence is 2%
For age group 15-24 yrs: 20.9%
Sex: more common in males
Nutrition
Incubation period: 3 to 6 weeks
Reservoir: human
Period of communicability

12. TB IS A SOCIAL DISEASE WITH
MEDICALASPECTS
Poor quality of care
Poor housing and overcrowding
Population explosion
Undernutrition
Lack of education
Large families
Lack of awareness of causes of illness
Social stigma

14. Close contact with someone who has active TB
Immunocompromised status
Substance abuse
Any person with inadequate health care
Preexisting medical conditions
Institutionalization
Health care worker performing high-risk activities

18. ASSESSMENT AND DIAGNOSTIC EVALUATION
HISTORY-
History of present illness:
 Breathlessness, Cough
 Loss of weight, Loss of appetite
 Evening rise of temperature ,
 Palpitations, Wheezing, stridor
 Hematemesis, Epigastric pain
 Nausea, vomiting,
 Chest pain, Fever

19. .
History of past illness: Blood transfusion, heart transplantation, cardiac
bypass grafting, trauma, metabolic disorder, any toxin intake
Personal history: Food habits, any habit of cigarette smoking or alcohol
use or drug use
Family history: Disorder of respiratory system such as COPD,
pulmonary TB, etc.
Occupational history
Medical history: Previous history of surgery and medications if patient
is taking or any drug allergy and previous hospitalization history
Surgical history

20. .
PHYSICAL
EXAMINATION-
 Assessing the lungs for
consolidation by evaluating
breath sounds (diminished,
bronchial sounds; crackles),
fremitus, and egophony
 Clubbing of the fingers or
toes (in people with advanced
disease)

21. .
 Swollen or tender lymph nodes
in the neck or other area
 Fluid around lung (pleural
effusion)
 Clinical manifestations of
fever, anorexia, weight loss,
night sweats, fatigue, cough, and
sputum production prompt a
more thorough assessment of
respiratory function

22. TUBERCULIN SKIN TEST
•Tubercle bacillus extract
(tuberculin), purified protein
derivative (PPD), is injected into the
intradermal layer of the inner aspect
of the forearm, approximately 4
inches below the elbow. Intermediate-
strength PPD, in a tuberculin syringe
with a half-inch 26 gauge needle, is
used.

25. .
 A reaction occurs when both induration and erythema (redness)
are present.
 The size of the induration determines the significance of the
reaction.
• Erythema without induration is not considered significant
0 to 4 mm: not significant
5 mm or greater : may be significant in people who are
considered to be at risk.
10 mm or greater: significant

26. ABSENCE OF EVIDENCE OF
DISEASE IS NOT THE
EVIDENCE OF ABSENCE OF
DISEASE
 A significant reaction indicates past exposure to M.
Tuberculosis or vaccination with bacille calmette-guérin
(BCG) vaccine.

27. .
Rapid tests for TB include :
The QuantiFERON-TB gold in tube test (QFT-GIT),
The T-SPOT TB test (t-spot), and
The Xpert MTB/RIF.

28. .
•QuantiFERON-TB gold test (QFT-G) test
It is an enzyme linked immunosorbent assay (ELISA) that
detects the release of interferon-gamma by white blood
cells when the blood of a patient with TB is incubated with
peptides similar to those in M. Tuberculosis. The results of
the QFT-G test are available in less than 24 hours and are
not affected by prior vaccination with BCG.

30. .
Drug susceptibility testing- for all patients, the initial M.
Tuberculosis isolate should be tested for drug resistance, drug
susceptibility patterns should be repeated at 3 months for
patients who do not respond to therapy
Other test may include:
 Biopsy of the affected tissue
 Bronchoscopy
 Chest CT scan
 Thoracocentesis

31. PRESUMPTIVE TB CASE
DEFINITION
• Cough >2 weeks
• Fever> 2 weeks
• Significant weight loss
• Hemoptysis
• Any abnormality in chest radiography

35. -SPUTUM SMEAR
MICROSCOPY
-CHEST X RAY
-CBNAAAT

37. CBNAAT (CARTRIDGE BASED
NUCLEIC ACID AMPLIFICATION TEST)
It purifies, concentrates, amplifies (by rapid,
real-time PCR) and identifies targeted nucleic
acid it sequences in the TB genome and
provides results from unprocessed sputum
samples
It is for TB case detection and rifampicin
resistance testing

39. OBSTACLES TO TB CONTROL
• At least six months treatment
• Multiple medicines
• Relatively expensive
• No effective vaccine
• No new drugs on the horizon

40. FIRST LINE DRUGS SECOND LINE
DRUGS
THIRD LINE
DRUGS
 Isoniazid(H)
 Rifampicin (R)
 Pyrazinamide (Z)
 Ethambutol (E)
Streptomycin (S)-
Supplemental drug
 Fluoroquinolones:
• Ofloxacin
• ciprofloxacin
 Ethionamide
 Para aminosalicylic
acid (PAS)
 Cycloserine
 Injectable:
Capreomycin
Amikacin
 Rifabutin
 Macrolides e.g.
clarithromycin
 Linezolid
 Thioacetazone
 Thioridazine
 Arginine

41. CURRENT REGIMEN
TYPE OF
PATIENT
INTENSIVE
PHASE
CONTINUATION
PHASE
TOTAL
DURATION
NEW PATIENTS 2 months HRZE 4 months of HRE 6 months
PREVIOUSLY
TREATED
PATIENTS
2 months HRZES+
1 month of HRZE
5 months of HRE 8 months

42. FIXED DOSE COMBINATION
WEIGHT
CATEGORY
NO. OF TABLETS TO BE
CONSUMED
INJ.
STREPTOMYCIN
INTENSIVE
PHASE
CONTINUATION
PHASE
H R Z E H R E
75/150/400/275
mg/day
75/150/275
mg/day
25-39 kg 2 2 0.5 gm
40-54 kg 3 3 0.75 gm
55-70 kg 4 4 1.0 gm
>70 kg 5 5 1.0 gm

43. RECENT
CHANGES

44. DRUG RESISTANT TB
MONO DRUG Resistant to any one of HZE
RIFAMPICIN RESISTANT Resistant to R but sensitive to H
POLY DRUG Resistant to more than one of HZE
MULTI DRUG (MDR) Resistant to H + R
EXTENSIVE DRUG
RESISTANCE (XDR)
Resistant to H + R + one of FQ’s +
one of injectable
TOTAL DRUG RESISTANCE
(TDR)
Resistant to all available drugs for
TB

45. INH ALSO MAY BE USED AS A PROPHYLACTIC
(PREVENTIVE) MEASURE FOR PEOPLE WHO ARE
AT RISK FOR SIGNIFICANT DISEASE
Household family members of patients with active discase
Patients with HIV infection
Patients with fibrotic lesions
Patients whose current PPD test results show a change from
former test results, suggesting recent exposure to TB and
possible infection
Users of IV/injection drugs who have PPD test results with
10 mm of induration or more

46. Patients with high-risk comorbid conditions
35 years or younger who have PPD test results with 10 mm of
induration or more and one of the following criteria
-Foreign-born individuals from countries with a high prevalence
of TB
-High-risk, medically underserved populations
-Institutionalized patients
Prophylactic INH treatment : daily doses for 6 to 12 months.
Liver enzymes, blood urea nitrogen (BUN), and creatinine levels
are monitored monthly & Sputum culture results are monitored.

47. DOTS
Case detection by sputum smear microscopy
Standardized treatment regimen directly observed

48. Regular drug supplies
Government commitment
A standardized recording and reporting system

49. ADVANTAGES OF DOTS
•Cure rate as high as 95 percent
•Guarantees quicker and surer
relief from the disease
•It has changed the lives of 17 lakh
patients in India

59. RNTCP (REVISED NATIONAL
TUBERCULOSIS CONTROL
PROGRAMME)
•National TB program (NTP)- 1962- BCG vaccination
and TB treatment
•In 1978, BCG vaccination was shifted under the
expanded program on immunization (EPI).

60. .
• The WHO declared TB as a global emergency(1996)- (DOTS)
• NTP  Revised National TB Control program (RNTCP)
• DOTS was officially launched as the RNTCP strategy in 1997
and by the end of 2005 the entire country was covered under the
program

61. .
• RNTCP has released a ‘National Strategic Plan for
tuberculosis 2017-2025’ (NSP)
• According to the NSP TB elimination have been integrated
into the four strategic pillars of “detect – treat – prevent –
build” (DTPB).
• National Tuberculosis elimination program (NTEP)

62. .
DETECT
 Notification of Tb cases
 NIKSHAY: RNTCP has developed a case-based web-based TB
surveillance system called “NIKSHAY” for both government and
private health care facilities.
 Public private partnership: private providers are provided
incentives for Tb case notification, and for ensuring treatment
adherence and treatment completion.
 Free drugs and diagnostic tests to Tb patients in private sector

63. .
TREAT
 Provision of free Tb drugs
 Nikshya poshak yozana

66. .
PREVENT
 Contact tracing
 Isoniazid preventive therapy (IPT)
 BCG vaccination
 air-borne infection control measures at health care
facilities
 Addressing social determinants of TB like poverty,
malnutrition, urbanization, indoor air pollution, etc. Require
inter departmental/ ministerial coordinated activities and the
program is proactively facilitating this coordination

67. .
BUILD:
• Health system strengthening for TB control under the
national strategic plan 2017-2025 is recommended in the
form of building and strengthening enabling policies,
empowering institutions and human resources with enhanced
capacities.

68. IMPACT INDICATORS BASELINE (2015) TARGET (2025)
To reduce TB incidence rate
(per 1,00,000)
217 44
To reduce TB prevalence rate
(per 1,00,000)
320 65
To reduce estimated mortality
due to TB (per 1,00,000)
To achieve zero catastrophic
cost for TB affected families
32
35 %
3
0%

69. .
The BCG vaccine- preventive strategy
• It is given to produce a greater resistance to development of
TB.
• BCG has between 60% and 80% protective efficacy against
severe forms of Tb.

70. .
• The duration of protection of BCG is not
clearly known.
• The characteristic raised scar that BCG
immunization leaves is often used as
proof of prior immunization.
• BCG vaccine vial of 10 doses (0.05 ml)
for infants under one year old, to be
reconstituted with 0.5 ml of sodium
chloride injection.

72. DIETARY MANAGEMENT
Three meals should be taken each day consisting of juices and
fresh fruits like pineapples, melons, oranges, peaches, grapes,
and apples.
For drinks, unsweetened plain water or lemon water can be
taken either cold or hot.
glass of milk with each meal.

73. Energy rich foods- the GO
foods
Carbohydrates and fats-
whole grain cereals, millets,
vegetable oils, ghee, butter nuts
and oilseeds, fibre rich diet,
calcium and iron rich diet
Body building foods- the
GROW foods
Proteins-
Pulses, nuts and some oilseeds
Milks and milk products
Meat, fish, and poultry
Protective foods – the GLOW
foods
Vitamins and minerals-
Green leafy vegetables, other
vegetables and fruits, eggs, milk
and milk products and flesh foods

74. .
Avoid:
alcohol as it can make the condition worse and bring
about other complications.
foods like pickles, condiments, sauces, refined cereals,
pies, puddings, refined sugar, white bread, tinned and
canned foods, and caffeinated beverages.
tea, coffee, white flour and products made from them,
refined foods, fried foods, flesh foods

75. NURSING MANAGEMENT
Diagnosis: ineffective airway clearance related to secretions
present in tracheobronchial tree
Goal: promoting airway clearance
Diagnosis: improper medication adherence and compliance
related to side effects of drugs or long-term treatment plan
Goal: promoting adherence to treatment regimen and teaching
about the side effects of drugs and maintaining compliance

76. .
Diagnosis: activity intolerance and imbalanced nutrition, less
than body requirement related to the sign and symptoms due to
pulmonary tuberculosis
Goal: promoting activity and adequate nutrition
Diagnosis: risk of transmission related to unhygienic
practices and improper disposal of tissue or coughing
and sneezing
Goal: preventing transmission of tuberculosis infection

77. COMPLICATIONS
 Bones: spinal pain and joint destruction may result from TB that
infects bones (TB spine or potss spine)
 Brain (meningitis)
 Liver or kidneys
 Heart (cardiac tamponade)
 Pleural effusion
 TB pneumonia
 Serious reactions to drug therapy ( hepatotoxicity,
hypersensitivity)

79. RECOMMENDATIONS FOR PREVENTING
TRANSMISSION OF TUBERCULOSIS IN
HEALTH CARE SETTINGS
Early identification and treatment of persons with active
TB
A. Maintain a high index of suspicion for TB to identify cases
rapidly.
B. Promptly initiate effective multidrug anti-TB therapy
based on clinical and drug-resistance surveillance data

80. .
Prevention of spread of infectious droplet nuclei by source
control methods and by reduction of microbial contamination
of indoor air
A. Initiate AFB isolation precautions immediately
AFB isolation precautions :
• use of a private room with negative pressure in relation to
surrounding areas
• Air from the room should be exhausted directly to the outside.
• The use of ultraviolet lamps and/or high-efficiency particulate
air filters to supplement ventilation may be considered.

81. .
B. Persons entering the AFB isolation room should use
disposable particulate respirators that fit snugly around the
face.
C. Continue AFB isolation precautions until there is clinical
evidence of reduced infectiousness (i.e., Cough has
substantially decreased and the number of organisms on
sequential sputum smears is decreasing). If drug resistance is
suspected or confirmed, continue AFB precautions until the
sputum smear is negative for AFB.
D. Use special precautions during cough-inducing procedures.

82. .
Surveillance for TB transmission
A. By routine, periodic tuberculin skin testing. Recommend
appropriate preventive therapy for HCWS when indicated.
B. Maintain surveillance for TB cases among patients and HCW’s.
C. Promptly initiate contact investigation procedures among
HCWs, patients, and visitors
Recommend appropriate therapy or preventive therapy for
contacts with disease or tb infection without current disease.

83. GENERALADVISE
Isolation
Ventilate the room
Maintain distance
Wear mask
Finish entire course of medication
Vaccination
Healthy diet
Maintain hygiene

84. CONCLUSION
• Pulmonary tuberculosis is an bacterial infection of the lungs that can
cause a range of symptoms, including chest pain, breathlessness, and
severe coughing. Pulmonary tuberculosis can be a life threatening
condition if a person does not receive treatment on time. People with
active tuberculosis can spread the bacteria through droplet infection,
by sneezing or coughing.
• Compliance to the treatment is the most important concern for people
with pulmonary tuberculosis because drug resistance is a common
issue that develops and creates problem in getting treated accurately
and early.

86. BIBLIOGRAPHY
 Brunner and suddharths. Textbook of medical and surgical nursing. 13th edition vol. I.
.New delhi: reed elsevier india pvt. Ltd.; 2014. Pg. No. 580-596
 Lewis. Medical surgical nursing. Assessment and management of clinical problems. Vol.
I. 2015. New delhi. Elsevier pg. No. 461-493
 Joyce M. Black and jane hokanson; medical surgical nursing; volume 2, 8th edition, reed
elsevier, india pvt.
 Https://www.Lung.Org/lung-health-disease/lung-disease-lookup/tiberculosis/symptoms-
diagnosis
 Faqs :: central TB division (tbcindia.Gov.In)
 WHO | what is DOTS?
 Revised national tuberculosis control programme | national health portal of india
(nhp.Gov.In)

87. Research :
Saktiawati, antonia M I et al. “Impact of food on the pharmacokinetics of first-line anti-tb drugs
in treatment-naive TB patients: a randomized cross-over trial.” The journal of antimicrobial
chemotherapy vol. 71,3 (2016): 703-10. Doi:10.1093/jac/dkv394
 Kısa, bektaş et al. “Tuberculosis screening and efficacy of prophylaxis in contacts of patients
with pulmonary tuberculosis.” “Akciğer tüberkülozu temaslılarında hastalanma ve koruyucu
tedavinin etkinliği.” Tuberkuloz ve toraks vol. 64,1 (2016): 27-33. Doi:10.5578/tt.9167

88. .
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YOU