Pulmonary TB (Tuberculosis) PPT SlideShare

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 Pulmonary tuberculosis Extrapulmonary tuberculosis: Tuberculosis meningitis Renal and urogenital tuberculosis Bone and joint tuberculosis Tuberculosis enteritis Miliary tuberculosis Tuberculosis pleural effusion

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

5. 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%.

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

7. Sources of infection Human source Bovine source

8. 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

9. Tb is a social disease with medical aspects 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

10. . 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

11. 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

12. . 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

13. . 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)

14. . 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

15. 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.

16. . 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

17. 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.

18. . R apid tests for TB include : T he QuantiFERON-TB gold in tube test (QFT-GIT), The T-SPOT TB test (t-spot), and T he Xpert MTB/RIF.

19. . 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.

20. . 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

21. Presumptive Tb case definition Cough >2 weeks Fever> 2 weeks Significant weight loss Hemoptysis Any abnormality in chest radiography

22. -Sputum smear microscopy -chest x ray - cbnaaat

23. 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

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

25. 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

26. 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

27. 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

28. Recent changes

29. 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

30. 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

31. . 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.

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

33. . R egular drug supplies Government commitment A standardized recording and reporting system

34. 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

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

36. . The WHO declared TB as a global emergency (1996)- ( DOTS) NTP  Revised N ational 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

37. . RNTCP has released a ‘National S trategic P lan 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)

38. . 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

39. . TREAT Provision of free Tb drugs Nikshya   poshak yozana

40. . 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

41. . 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.

42. 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%

43. . 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.

44. . 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.

45. 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 .

46. 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

47. . 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

48. 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

49. . 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

50. 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)

51. 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

52. . 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.

53. . 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.

54. . Surveillance for TB transmission B y 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 HCW s, patients, and visitors Recommend appropriate therapy or preventive therapy for contacts with disease or tb infection without current disease.

55. GENERAL ADVISE Isolation Ventilate the room Maintain distance Wear mask Finish entire course of medication Vaccination Healthy diet Maintain hygiene

56. 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.

57. 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, 8 th 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 )

58. 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

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