[PPT]Chapter 7 Body Systems · Web viewTitle Chapter 7 Body Systems Author Linda Honeycutt Last modified by Norma Driscoll Created Date 1/16/2005 5:28:53 PM Document presentation

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 17Chapter 17 Tuberculosis Tuberculosis

Figure 17-1. Tuberculosis. A, Early primary infection. B, Cavitation of a caseous tubercle and new 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 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 infections. Note the subpleural location of some of these lesions. D, Severe lung destruction caused by tuberculosis. tuberculosis.

A

C

B

D


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

(Three categories)(Three categories) Primary tuberculosisPrimary tuberculosis

Primary infection stagePrimary infection stage

Postprimary tuberculosisPostprimary tuberculosis Secondary or reinfection TBSecondary or reinfection TB

Disseminated tuberculosisDisseminated tuberculosis Extrapulmonary TBExtrapulmonary TB


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs(Mainly Primary TB)(Mainly Primary TB)

Alveolar consolidationAlveolar consolidation Alveolar-capillary destructionAlveolar-capillary destruction Caseous tubercles or granulomasCaseous tubercles or granulomas Fibrosis and secondary calcification of the Fibrosis and secondary calcification of the

lung parenchymalung parenchyma Distortion and dilation of the bronchiDistortion and dilation of the bronchi Increased bronchial airway secretionsIncreased bronchial airway secretions


EtiologyEtiology

In human, TB primarily caused by In human, TB primarily caused by Mycobacterium tuberculosisMycobacterium tuberculosis

OthersOthers Mycobacterium bovisMycobacterium bovis Mycobacterium ulceransMycobacterium ulcerans Mycobacterium kansasiiMycobacterium kansasii Mycobacterium avium-intracellulareMycobacterium avium-intracellulare

Highly aerobic organismsHighly aerobic organisms


DiagnosisDiagnosis

Intradermal tuberculin skin testingIntradermal tuberculin skin testing Mantoux testMantoux test Injection of purified protein derivative (PPD)Injection of purified protein derivative (PPD)

• Wheal <5 mm: negativeWheal <5 mm: negative

• Wheal 5 mm to 9 mm: considered suspiciousWheal 5 mm to 9 mm: considered suspicious

• Wheal 10 mm or greater: positiveWheal 10 mm or greater: positive


DiagnosisDiagnosis

Acid-fast stain and sputum cultureAcid-fast stain and sputum culture Ziehl-Neelsen stainZiehl-Neelsen stain

• Reveals bright red acid-fast bacilli against a blue backgroundReveals bright red acid-fast bacilli against a blue background

Fluorescent acid-fast stainFluorescent acid-fast stain• Reveals luminescent yellow-green bacilli against a dark brown Reveals luminescent yellow-green bacilli against a dark brown

backgroundbackground

A culture is necessary to differentiate A culture is necessary to differentiate M. tuberculosisM. tuberculosis form other acid-fast organismsform other acid-fast organisms• Results take as long as 6 to 8 weeksResults take as long as 6 to 8 weeks


DiagnosisDiagnosis

Identification of Identification of MycobacteriumMycobacterium species species Polymerase chain reaction (PCR)Polymerase chain reaction (PCR)

• Quick identification of organisms in expectorated or Quick identification of organisms in expectorated or bronchoscopically obtained sputumbronchoscopically obtained sputum

Deoxyribonucleic acid (DNA) probeDeoxyribonucleic acid (DNA) probe


Nontuberculosis MycobacteriaNontuberculosis Mycobacteria

Mycobacterial infection caused by species Mycobacterial infection caused by species other than other than M. tuberculosisM. tuberculosis are called are called nontuberculosis mycobacteria (NTM)—also nontuberculosis mycobacteria (NTM)—also called:called: Mycobacteria other than tuberculosis (MOTT)Mycobacteria other than tuberculosis (MOTT) Atypical mycobacterial infectionAtypical mycobacterial infection

Found in soil and waterFound in soil and water


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with TUBERCULOSISwith TUBERCULOSIS

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Alveolar ConsolidationAlveolar Consolidation (see (see Figure 9-8), and Figure 9-8), and Increased Alveolar-Capillary Increased Alveolar-Capillary Membrane ThicknessMembrane Thickness (see Figure 9-9)—the (see Figure 9-9)—the major anatomic alterations of the lungs major anatomic alterations of the lungs associated with tuberculosis (see Figure 17-1). associated with tuberculosis (see Figure 17-1).


Figure 9-8. Alveolar consolidation clinical scenario.Figure 9-8. Alveolar consolidation clinical scenario.


Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.


Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

Vital signsVital signs Increased respiratory rateIncreased respiratory rate Increased heart rate, cardiac output, Increased heart rate, cardiac output,

blood pressureblood pressure


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Chest pain/decreased chest expansionChest pain/decreased chest expansion CyanosisCyanosis Digital clubbingDigital clubbing Peripheral edema and distentionPeripheral edema and distention

Distended neck veinsDistended neck veins Pitting edemaPitting edema Enlarged and tender liverEnlarged and tender liver


Digital Clubbing

Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.


DistendedDistendedNeck VeinsNeck Veins

Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).


Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Cough, sputum production, and hemoptysisCough, sputum production, and hemoptysis Chest assessment findingsChest assessment findings

Increased tactile and vocal fremitusIncreased tactile and vocal fremitus Dull percussion noteDull percussion note Bronchial breath soundsBronchial breath sounds Crackles, rhonchi, and wheezingCrackles, rhonchi, and wheezing Pleural friction rubPleural friction rub Whispered pectoriloquyWhispered pectoriloquy


Figure 2-11. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.of alveolar consolidation.


Figure 2-16. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung Auscultation of bronchial breath sounds over a consolidated lung unit.unit.


Figure 2-19. Figure 2-19. Whispered voice sounds auscultated over a normal lungWhispered voice sounds auscultated over a normal lungare usually faint and unintelligible.are usually faint and unintelligible.


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVC FEVT FEF25%-75% FEF200-1200

N or N or N

PEFR MVV FEF50% FEV1% N N or N N or


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VT RV FRC TLC N or

VC IC ERV RV/TLC% N


Arterial Blood GasesArterial Blood Gases

Mild to Moderate TuberculosisMild to Moderate Tuberculosis Acute alveolar hyperventilation with Acute alveolar hyperventilation with

hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease

100

50

30

80

0

PaCO2

10

20

40

Alveolar Hyperventilation

60

70

90 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetPa

O2 o

r PaC

O2

Figure 4-2. PaO2 and PaC02 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Extensive Tuberculosis with PulmonaryExtensive Tuberculosis with PulmonaryFibrosisFibrosis Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

Normal (Significantly)


Time and Progression of Disease

100

50

30

80

0

PaO2

10

20

40

Alveolar Hyperventilation

60

70

90Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Chronic Ventilatory FailureDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Pa0 2

or P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.


Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure

Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure

Acute ventilatory failure on chronic ventilatory Acute ventilatory failure on chronic ventilatory failurefailure


Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2


Hemodynamic Indices Hemodynamic Indices (Severe Tuberculosis)(Severe Tuberculosis)

CVP CVP RAPRAP PAPA PCWPPCWP

NormalNormal

COCO SVSV SVISVI CICI

NormalNormal NormalNormal NormalNormal Normal Normal

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR

NormalNormal NormalNormal


Abnormal Laboratory TestsAbnormal Laboratory Testsand Proceduresand Procedures

Positive tuberculosis skin test (PPD)Positive tuberculosis skin test (PPD) Positive acid-fast bacillus stain of sputumPositive acid-fast bacillus stain of sputum

and sputum cultureand sputum culture


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph Increased opacityIncreased opacity Ghon’s complexGhon’s complex Cavity formationCavity formation Pleural effusionPleural effusion Calcification and fibrosisCalcification and fibrosis Retraction of lung segments or lobeRetraction of lung segments or lobe Right ventricular enlargementRight ventricular enlargement


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


General Management of General Management of TuberculosisTuberculosis

Pharmacologic agents Pharmacologic agents Consists of 2 to 4 drugs for 6 to 12 monthsConsists of 2 to 4 drugs for 6 to 12 months

First-line agents (first 9 months)First-line agents (first 9 months)• Isoniazid (INH) and rifampin (Rifadin)Isoniazid (INH) and rifampin (Rifadin)

• INH most effectiveINH most effective

Often supplemented with:Often supplemented with:• EthambutolEthambutol

• StreptomycinStreptomycin

• Pyrazinamide Pyrazinamide


General Management of General Management of TuberculosisTuberculosis

Respiratory care treatment protocolsRespiratory care treatment protocols Oxygen therapy protocolOxygen therapy protocol Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol Hyperinflation therapy protocolHyperinflation therapy protocol Mechanical ventilation protocolMechanical ventilation protocol


ReviewReview

The protective cell wall that surrounds and The protective cell wall that surrounds and encases the TB bacilli is called -?encases the TB bacilli is called -? Tubercle or granulomaTubercle or granuloma

What is primary TB?What is primary TB? Reaction following first exposure to pathogenReaction following first exposure to pathogen

• Inflammation leading to alveolar consolidationInflammation leading to alveolar consolidation

• Formation of tubercleFormation of tubercle

• Fibrosis and calcification, development of bronchiectasisFibrosis and calcification, development of bronchiectasis


What is postprimary TB?What is postprimary TB? Reactivation of TB after initial infection has been Reactivation of TB after initial infection has been

controlledcontrolled

What is dissemminated TB?What is dissemminated TB? Infection that spreads to sites outside the lung via Infection that spreads to sites outside the lung via

pulmonary lymphatic system or bloodstreampulmonary lymphatic system or bloodstream

The presence of numerous small tubercles The presence of numerous small tubercles scattered throughout the body is called - ?scattered throughout the body is called - ? Miliary tuberculosisMiliary tuberculosis


How long can TB bacillus remain suspended How long can TB bacillus remain suspended in the air after a sneeze or a cough?in the air after a sneeze or a cough? Several hoursSeveral hours

What is a Ghon’s complex?What is a Ghon’s complex? Combination of tubercles and hilar Combination of tubercles and hilar

lymphadenopathy seen on CXRlymphadenopathy seen on CXR

Typical ABG’s from a patient with extensive Typical ABG’s from a patient with extensive TB and fibrosis would be describe as - ?TB and fibrosis would be describe as - ? Chronic Ventilatory failure and hypoxemiaChronic Ventilatory failure and hypoxemia


What hemodynamic indices reflect right-side What hemodynamic indices reflect right-side heart failure in a patient with advanced TB?heart failure in a patient with advanced TB? Increased CVPIncreased CVP Increased RAPIncreased RAP Increased mean PAIncreased mean PA Increased PVRIncreased PVR Increased RVSWIIncreased RVSWI

What respiratory care treatments/protocols are What respiratory care treatments/protocols are used for TB?used for TB? O2 TherapyO2 Therapy BHTBHT Hyperinflation TherapyHyperinflation Therapy


True or FalseTrue or False Pleural space complications such as Pleural space complications such as

empyema and pneumothorax are common in empyema and pneumothorax are common in patients with tuberculosis.patients with tuberculosis. TrueTrue

A positive reaction to the tuberculin skin test A positive reaction to the tuberculin skin test confirms that a patient has active tuberculosisconfirms that a patient has active tuberculosis FalseFalse

Tuberculosis commonly develops in the Tuberculosis commonly develops in the apices of the lungsapices of the lungs TrueTrue


Classroom DiscussionClassroom DiscussionCase Study: TuberculosisCase Study: Tuberculosis

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[PPT]Chapter 7 Body Systems · Web viewTitle Chapter 7 Body Systems Author Linda Honeycutt Last modified by Norma Driscoll Created Date 1/16/2005 5:28:53 PM Document presentation