Understanding Pulmonary Tuberculosis: Causes, Symptoms, and Treatment Options

What is Tuberculosis (TB)

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis,which is an aerobic acid-fast bacillus. It is an infectious disease that primarily affects the lung parenchyma. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection. It usually involves the lungs but it can occur in the kidneys, bones, adrenal glands, lymph nodes and meninges, and can also be disseminated throughout the body. TB of the lungs is called Pulmonary TB, Mycobacterium infection outside the lungs is called Extrapulmoary TB.M. tuberculosisis usually spread via airborne droplets from infected people when they cough, sneeze, or speak. TB is not highly infectious and requires prolonged exposure by an individual before they can be infected. TB is not spread by hands, books, glasses, or dishes.

Risk factors of Tuberculosis

• Institutionalization (e.g. long-term care facilities, psychiatric institutions, prisons)
• Living in overcrowded, substandard housing (overcrowding)
• Any person without adequate health care (the homeless, impoverished)
• IV or injection drug abuse
• Smoking and alcoholism
• Occupations such as nursing, mining companies, quarries etc.
• Pre-existing medical conditions or special treatment (e.g., diabetes,chronic renal failure,malnourishment, HIV, cancers)
• Silicosis

Pathophysiology of Tuberculosis

When an individual inhales the bacilli, they move along the upper respiratory tract and localize in the bronchi and alveoli. They multiply and implant in the lower parts of the lungs. Initially, the bacilli multiply without host resistance. Later, the organisms are engulfed by phagocytes within which they may continue to multiply whilst cellular immune response is being activated. While cellular immune response is being activated, the bacilli are also transported via the lymphatic system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes).
Eventually, host cellular immunity is activated and reduces the spread of the infection by forming epitheloid cell granulomas (or epitheloid tubercle). This progresses to necrosis (caseous necrosis). Caseous necrosis progresses to sloughing and cavitation of the lung tissue, resulting in the signs and symptoms of tuberculosis.

Signs & Symptoms of Tuberculosis

• Cough (cough for more than 3 weeks could be TB) – this is initially non productive but later becomes mucopurulent
• Weight loss (as much as 10kg or more)
• Pallor
• Dyspnoea
• Fatigue
• Malaise
• Anorexia
• Low grade fever
• Night sweats
• Chest pain
• Hemoptysis
• Premenopausal women may experience irregular menses

TB Diagnostic Test & Investigations

• Tuberculin skin test: This involves the IM injection of 0.1ml of Purified Protein Derivatives (PPD). The test result is read 48 to 72 hours after injection at the site of injection. Positive patients will experience skin reaction of redness, swelling and induration.
• Three sputum smears for culture and sensitivity: Spot specimen – ask patient to give you a specimen on his first visit. Early morning sputum – since AFB is more active in the night. Third morning specimen on arrival with early morning specimen.
• Chest X-ray for lung cavitations
• Erythrocyte sedimentation rate (ESR) for inflammation
• Full blood count for low Hb and high WBCs
• Physical examination for signs and symptoms.
• ELISA (enzyme-linked immunosorbent assay) to measure IgG antibody against Mycobacterial antigens.

Treatment of Tuberculosis

• Pulmonary (TB) is treated primarily with chemotherapeutic agents (anti-tuberculosis agents) for 6 to 12 months.
• Prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.
• There is a combination of at least four drugs in treating TB using DOTS (Directly Observed Therapy) short course.
• Directly Observed Therapy short course means that the patient is kept under strict observation for at least the first two months during treatment.
• A person is considered noninfectious after 2 to 3 weeks of continuous medication therapy.
• Treatment is divided into intensive phase and continuation phase with fixed-dose combination tablets.
• The first two months is known as the intensive phase and the remaining months is the continuation phase.
• The first two months is very crucial, and here the client is admitted, and strictly observed so that there will be no break in treatment.
• Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), and Streptomycin (S) are used.
• Rifampicin can react with some antiretroviral drugs – should be noted in HIV patients with TB.

• HRZE is used for the initial phase and HR is used for the continuation phase

• SHRZE is used for the initial phase and HRE is used for the continuation phase

• HRZ is used for initial phase and HR is used for the continuation phase

Nursing Management of Tuberculosis

The subsequent measures are essential for effectively caring for patients with Tuberculosis (TB)

• Reassure patient and give emotional support.
• Ensure proper mouth care because of secretions
• Assist patient with bathing and activities of daily living because of weakness or fatigue
• Educate patient on adherence to the medication regimen
• Educate patient on covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene.
• Position the patient in a fowler or semi-fowler’s position to enhance respiratory comfort and to relieve chest pain.
• Teach and assist patient with coughing and deep breathing exercises to localize and bring out or expel sputum.
• Promote bed rest and activity restrictions
• Educate patient on complications of TB such as recurrence and hemorrhage.
• Educate patient on the need for proper nutrition.
• Educate the family members of patients that they need regular TB testing to ensure that they have not contracted TB.
• Educate patient to avoid overcrowding.
• Monitor and record patient’s vital signs to assess improvement in condition.
• Give sputum mug to patient and observe sputum for colour, quantity and consistency.
• Monitor the desired and adverse effects of drugs.
• Weigh patient daily to assess weight
• Assess patient’s chest pain
• Encourage intake of adequate fluids to liquefy bronchial secretions.
• Serve easily digested foods to conserve energy and prevent dyspnea.
• Serve food in bits and at frequent intervals
• Serve food rich in carbohydrates, protein, vitamins and minerals to enhance healing and boost patient’s immunity.

Preventions of Tuberculosis

• Early detection and treatment as well as screening of contacts
• Avoiding excessive intake of alcohol and smoking
• Avoiding exposure to crowds and others with upper respiratory infections.
• Proper ventilation
• Good housing and rooms to avoid overcrowding
• Adequate nutrition
• Avoiding the use of narcotic drugs
• Ensuring environmental hygiene
• Isolation of TB patients
• Immunization of children against TB by giving them BCG
• Health education on the condition