5. Introduction
• Patient may develop symptoms insidiously and some may
remain asymptomatic
• Patient with TB present with constitutional and respiratory
symptom
• Constitutional symptoms: tiredness, headache, weight loss,
fever, night sweats and loss of appetite
• Classic sign and symptom of TB are significantly higher
proportion in younger than elderly : fever (62% vs 31%),
weight loss (76% vs 34%), night sweats (48% vs 6%),
sputum production (76% vs 48%) and hemoptysis (40 %
vs 17%)
6. Cough: Definition
• Cough is an explosive expiration that provides a normal
protective mechanism for clearing the tracheobronchial
tree of secretions and foreign material.
7. Cough-Types
Cough is mainly classified as:
a) Productive / Useful / Effective
It used to drain secretions or mucous from the lungs.
This type of cough is mostly acute in nature and often
caused by bacterial or viral or fungal infection.
This type of cough should not be suppressed because here
the purpose of the cough is to remove mucus from
airways.
Suppression of this type of cough leads to recurrent or
constant infection.
8. Cough can also be classified as:
Acute - less than three weeks duration eg. infective
cough
Chronic - more than three weeks duration - for example,
smoker’s cough
Paroxysmal cough - spasmodic and recurrent
Bovine cough - soundless cough due to paralysis of larynx
Psychogenic cough - self-conscious activity of the patient
to draw attention
9. Cough Reflex
Coughing may be initiated either voluntarily or reflexively
and has both afferent and efferent pathways.
The afferent limb includes receptors within the sensory
distribution of the trigeminal, glossopharyngeal, superior
laryngeal, and vagus nerve in the nose, nasopharynx,
larynx, auditory canal, trachea, pulmonary bronchus and
pleura.
They report about the excess mucous or foreign substance
to the cough center which is located in the medulla of the
brain for inducing cough.
10. Cough Reflex contd…
Receptors are sensitive to
Touch of inhaled foreign body
Irritant gases like nitric acid, sulphuric acid, ammonia
Excessive secretions or mucous in nose, throat, sinuses
and lungs
Oedema or infection with pus in the airway
Exposure to extreme hot or cold air
The efferent limb includes the recurrent laryngeal nerve
and the spinal nerves.
The cough starts with a deep inspiration followed by
glottic closure, relaxation of the diaphragm, and muscle
contraction against a closed glottis.
11. Cough Reflex contd…
The resulting markedly positive intrathorasic pressure
causes narrowing of the trachea.
Once the glottis opens, the large pressure differential
between the airways and the atmosphere coupled with
trachea narrowing produces rapid flow rates through the
trachea.
The shearing forces that develop aid in the elimination of
mucus and foreign materials.
Normally, people cough voluntarily once or twice during
early morning or daytime to clear the throat or lungs.
12. ETIOLOGY
a) Infection - bacteria, virus and fungus.
b) External factors - by dust, cold, pollens, smoking and other
environmental irritants.
c) Drugs of hypertension and heart diseases (ACE inhibitors, beta
blockers).
d) Foreign body in the pharynx, nose, larynx, trachea, bronchus,
oesophagus.
e) Internal factors -
Sinuses - Postnasal drip
Heart - Congestive heart failure
Lung - Asthma, chronic bronchitis, cancer, emphysema,
bronchiectasis, tuberculosis
Pressure on lung- mediastinal lymphadenopathy,aneurysm,
thyromegaly
Ear - Otitis media, CSOM, impacted cerumen and foreign body
Stomach - Gastro oesophageal reflux
f) Psychogenic factors - habit of clearing mucous, for drawing
attention.
13. TYPES OF COUGH (contd..)
b) Non-productive / Ineffective / Dry
It is a dry, irritating cough without bring any secretions
or mucous from the lungs
This type of cough is chronic in nature and caused by dry
irritation or dust or smoke or fumes, or due to oedema
and mild secretion in the resolving stage of illness.
It may be also due to weakness of the muscles of
respiration, thick viscid mucus and in diseases of the cilia
which helps mucous transportation in the airway.
14. Tuberculosis and Cough
• Cough : MC symptom,
• Dry or productive
• Expectoration: mucoid, mucopurulant, purulant or blood
tinged and is usually scanty
• Cough of more than 2 wks duration should be investigated
for tuberculosis.
15. Massive hamoptysis
Definition of massive hemoptysis is variable in the
literature and has ranged from 100 mL/24 hrs to 1000
mL/24 hrs. The most commonly accepted definition of
massive hemoptysis is 600 mL/24 hrs.
Life-threatening process requiring immediate evaluation
and treatment.
1.5- 5% of all patients presenting with hemoptysis.
Mortality: 7-30%
Source of massive hemoptysis is usually systemic(95%)
rather than pulmonary circulation (5%).
16. Vascular origin of hemoptysis
Blood traversing the lungs can arrive from
pulmonary arteries, or
bronchial arteries
Virtually the entire cardiac output courses through the low-
pressure pulmonary arteries and arterioles en route to being
oxygenated in the pulmonary capillary bed .
In contrast, the bronchial arteries are under much higher systemic
pressure but carry only a small portion of the cardiac output
17. Vascular origin of hemoptysis
Despite the quantitatively smaller contribution of the
bronchial circulation to pulmonary blood flow, the
bronchial arteries are generally a more important source of
hemoptysis than the pulmonary circulation.
In addition to being perfused at a higher pressure, they also
supply blood to the airways and to lesions within the
airways.
19. Tuberculosis and Hemoptysis
Tuberculosis can cause massive hemoptysis through multiple
mechanisms
In active disease
Endobronchitis
Rupture of Rasmussen’s aneurysm
Oozing from the wall of active pulmonary cavitary lesions
Invasion of blood vessels by active granulation tissue
In healed disease
Impigement of healed calcified lymph node on bronchial artery
Bleeding from the wall of a cavity with mycetoma
Scar carcinoma
Bronchiectatic lesions
20. DYSPNEA
• Dyspnea refers to the sensation of difficult or
uncomfortable breathing when the patient becomes aware
of his own breathing. It is a subjective experience
perceived and reported by an affected patient.
• Dyspnea on exertion (DOE) may occur normally, but is
considered indicative of disease when it occurs at a level of
activity that is usually well tolerated
• Dyspnea should be differentiated from tachyapnea,
hyperventilation, and hyperpnoea, which refer to
respiratory variations regardless of the patient’s subjective
sensations.
21. MEDICAL RESEARCH COUNCIL DYSPNOEA SEVERITY SCALE
Grade Degree Characteristics
0 None Only with strenuous activity
1 Slight
When hurrying on level ground or climbing
a slight incline
2 Moderate
Needs to walk more slowly than others of
the same age or has to stop for breath
when walking at own pace on level ground
3 Severe
Stops for breath after 100 yards or after a
few minutes
4 Very severe
Housebound or dyspnea when dressing or
undressing
22. Tuberculosis and Dyspnea
• In TB, Breathlessness is due to extensive disease
(parenchymal loss or decreased researve) or if
complication such as bronchial obstruction, pneumothorax
or pleural effusion occurs
23. Chest Pain
• Dull aching in character
• Acute chest pain may be due to TB pleurisy or in
pneumothorax with severe pain occurring at the height of
inspiration
• In diaphragmatic pleurisy pain may be referred to
ipsilateral shoulder when central part of diaphragm is
involved
• Occasional chest pain may be due to fracture of rib due to
violent coughing
25. Physical signs
• Anaemia
• Cachexia
• Anasarca
• Low BMI
• Leuconychia and digital clubbing
• lymphadenopathy
26. Respiratory system
• Decrease movement on the affected side
• Trail’s sign
• Dull percussion note – cracked pot sign
• Tubular, cavernous or emphoric breath sounds
• Vocal fremitus decreased
• Post-tussive crepitation
• Post-tussive suction
• Hippocratic succussion splash
27. Summary
• Cough,expectoration,chest pain,hemoptysis and dyspnea
are cardinal symptom of respiratory system.
• Tuberculosis apart from cardinal symptom has lot of non-
specific symptoms that should be kept in mind.
• Every patient with cough more than 2 weeks duration
should be evaluated for tuberculosis.
• In India, consolidation not responding to broad spectrum
antibiotics is tubercular in origin in most cases.
28. Bibliography
• Fishman’s textbook of pulmonary diseases and disorders.
Fourth edition
• Crofton and Douglas’s- Respiratory diseases. Fifth edition
• Sharma and Mohan: Textbook of tuberculosis: second
edition
• Toman’s Tuberculosis
31. PURPOSE OF STATEMENT
Aim of the Lecture is to teach students about
Aetiopathogenesis, Clinical Features, Diagnosis
& Treatment
32. LEARNING OBJECTIVES:
S.N
o.
Learning Objective Domain Level Criteria Conditions
1 Definition,
Aetiopathogenesis
Cognitive Must
Know
Nil Nil
2 Clinical Features Cognitive Must
Know
Nil Nil
3 Diagnosis Cognitive Must
Know
Nil Nil
4 Treatment Cognitive Must
Know
Nil Nil
5 Newer Treatment Cognitive Must
Know
Nil Nil
33. Tuberculosis
• Major public health problem in India
• TB is the number one killer of adults among all infectious
diseases, in India
• In India, more than 40 % of the population is infected with
tuberculosis infection
• Every year approximately 18 lakh people develop TB and
4 lakh die from it.
• In India, every day more than 5000 develop TB and more
than 1000 people die of TB (i.e 1 death every 11/2
minutes)
34. National Tuberculosis
programme(NTP)
• NTP was established in 1962 to combat the disease
• The nodal administrative unit was district – district tuberculosis
programme
• The basic strategy was to diagnose TB patients on the basis of clinical
suspicion, sputum examination and chest X-ray among the self
symptomatic
• There was little impact on TB burden in 1992 because of
a) Low priority
b) Managerial weaknesses
c) Over dependence on chest x-ray for diagnosis
d) Inadequate funding
e) Lack of supervision
f) Low rates of treatment adherence
35. RNTCP
• To understand various issues involved in the poor NTP
Government of india conducted in depth review of NTP in
1992
• As a result of observation and recommendation of this
review , Govt. identified the weak area and NTP become
RNTCP
• This Revised National Tuberculosis Control Programme
(RNTCP) uses the DOTS (Directly Observed Treatment,
Short-course chemotherapy) strategy, which is based on
results of tuberculosis research done in India.
• The “DOTS strategy” is the globally accepted standard
for diagnosis and treatment of tuberculosis.
36. RNTCP - Goals and Objectives
Goals - decrease mortality and morbidity due to TB and
cut transmission of infection until TB ceases to be a major
public health problem.
Objectives
• To achieve and maintain a cure rate of at least 85% among
newly detected infectious (new sputum smear-positive)
cases, and
• To achieve and maintain detection of at least 70% of such
cases in the population
37. DOTS-5 Components
Political and administrative commitment
Good quality diagnosis, primarily by sputum smear
microscopy
Uninterrupted supply of good quality drugs
Directly observed treatment (DOT)
Systematic monitoring and accountability
38. Structure of RNTCP
The structure of RNTCP comprises of five levels, as
follows:
1 National
2 State
3 District
4 Sub-district
5 Peripheral health institutions
A major organizational change is the creation of a sub-
district level – the tuberculosis unit (TU) for the
systematic monitoring and supervision of diagnostic and
treatment aspects of the programme.
39. UNIQUE features of RNTCP
District TB Control society (DTCS)
Sub-district level supervisory staff for microscopy and
treatment services (MOTC, STS and STLS) – provision of
two-wheelers for supervision by STS/STLS
Modular training for all staff Patient-wise treatment boxes
(PWB)
Robust recording and reporting system
Quarterly review of performance at all levels
40. Sub-district level (Tuberculosis Unit level)
• TU covers a population of approximately 5 Lakhs (2.5 Lakhs
in tribal, desert, remote and hilly regions).
• The TU will have one Microscopy Centre for every 1 Lakh
population (0.5 Lakh in tribal, desert, remote and hilly regions)
referred to as the Designated Microscopy Centre (DMC).
• The TU is the nodal point for TB control activities in the sub-
district. MOTC at the TU has the overall responsibility of
management of RNTCP at the sub-district level and is assisted
by the STS and STLS.
• MO-TC is also responsible for involvement of other sectors in
RNTCP. The MO-TC is trained in RNTCP at a state level
institution, preferably State TB Training and Demonstration
Centre (STDC).
41. Diagnostic algorithm of Pulm. TB
Cough of 2 wks or
more
Two sputum
smear
Two negative
Antibiotic for 10-
14 days
Cough persist
Repeat sputum smear examination
One or two
positive
Sputum smear
positive TB
Negative
X Ray
One or two positive
Xray S/O TB Non-TB
Sputum smear negative TB
42. RNTCP-Definitions
Pulmonary tuberculosis- smear positive
2 sputum smear positive for AFB OR one sputum positive
for AFB + CXR s/o active pulmonary TB Or: one sputum
and culture positive for AFB
Smear-negative patient
Symptoms suggestive of TB + 3 sputum examinations
negative for AFB + radiographic abnormalities consistent
with active pulmonary TB
Or:
Culture positive for M. tuberculosis but sputum smear
examinations negative for AFB.
43. RNTCP-Definitions
Extra-pulmonary tuberculosis
• Extra-pulmonary tuberculosis is tuberculosis of organs
other than the lungs, such as the pleura (pleurisy), lymph
nodes, intestines, genito-urinary tract, skin, joints and
bones, meninges of the brain, etc.
44. AFB Staining
ZIEHL–NEELSEN STAINING PROCEDURE
• Make a smear from yellow purulent portion of the sputum
• Allow the slide to air dry for 15–30 minutes.
• Fix the slide by passing it over flame 3–5 times for 3–4
seconds each time.
• Pour 1% filtered carbol fuchsin to cover the entire slide.
• Gently heat the slide with carbol fuchsin on it, until vapours
rise. Do not boil.
• Leave carbol fuchsin on the slide for 5 minutes.
45. AFB Staining
• Gently rinse the slide with tap water until all free carbol
fuchsin stain is washed away. Pour 25% sulphuric acid
onto the slide. Let the slide stand for 2–4 minutes.
• Pour 0.1% methylene blue onto the slide. Leave methylene
blue on the slide for 30 seconds.
• Rinse gently with tap water.
• Examine the slide under the microscope using x40 lens to
select the suitable area and then examine under x100 lens
using a drop of immersion oil.
46.
47. RNTCP-Case definition
New case A TB patient who has never had treatment for
tuberculosis or has taken antituberculosis drugs for less
than one month.
Relapse A TB patient who was declared cured or treatment completed
by a physician, but who reports back to the health service
and is now found to be sputum smear-positive.
Treatmen
t after
default
A TB patient who received anti-tuberculosis treatment for
one month or more from any source and returns to treatment
after having defaulted, i.e., not taken anti-TB drugs
consecutively for two months or more, and is found to be
sputum smear-positive.
Chronic A TB patient who remains smear-positive after completing a re-treatment
regimen.
48. RNTCP-Case definition
Failure Any TB patient who is smear-positive at 5
months or more after starting treatment.
Failure also includes a patient who was treated
with Category III regimen but who becomes
smear-positive during treatment.
Transferred in A TB patient who has been received for
treatment in a Tuberculosis Unit, after starting
treatment in another unit where s/he has been
registered.
Others TB patients who do not fit into the above
mentioned types. Reasons for putting a patient in
this type must be specified.
49. Treatment categories
Category of
Treatment
Type of Patient Regimen*
Category I New sputum smear-positive
Seriously ill** new sputum smear-
negative
Seriously ill** new extra-pulmonary
2H3R3Z3E3+
4H3R3
Category II Sputum smear-positive Relapse
Sputum smear-positive Failure
Sputum smear-positive Treatment After
Default
Others***
2H3R3Z3E3S3 +
1H3R3Z3E3 +
5H3R3E3
Category III New Sputum smear-negative, not
seriously ill
New Extra-pulmonary, not seriously ill
2H3R3Z3 +
4H3R3
50. Treatment categories
Category of
Treatment
Type of Patient Regimen*
IP CP
New (Cat-I) Sputum smear positive
Sputum smear negative
Extrapulmonary
Others
2H3R3Z3E3+ 4H3R3
Previously
treated(cat-
II)
Sputum Positive relapse
Sputum positive Failure
Sputum positive treatment after default
Others
2H3R3Z3E3S3 +
1H3R3Z3E3
5H3R3E3
MDR-
TB(Cat-IV)
Smear or culture positive MDR-TB K/Ethio/Cycl/Q/
E/Z
Ethio/Cycl/Q/E
H-600 mg R-450 mg E-1200 mg Z-1500 mg S- 750 mg
1
2 Patient with weight 60 kg or more receive additional Rifampicin 1
3 Patient with age more than 50 yrs receive streptomycin 500 mg
4 Patient with weight <30 kg receive drugs as per pediatric weight b
51. Regimens for non-DOTS(ND)treatment in
RNTCP areas
Treatment Types of patients Regimen
Non-DOTS Regimen 1
(ND1)
Smear- positive
pulmonary
Smear negative
pulmonary, seriously ill
Extra-pulmonary, not
seriously ill
2HSE +10HE
Non-DOTS Regimen 2
(ND2)
Smear-negative pulmonary,
not seriously ill
Extra-pulmonary, not
seriously ill
12 HE
Up to a maximum of 5% of patients may get non-DOTS
treatment
RNTCPnon-DOTS treatment (self administered non rifampicin containi
needed in exceptionally few cases (e.g. adverse reaction to rifampicin an
52. Summary
• A patient with productive cough more than 2 weeks should be
evaluated as diagnostic algorithm of pulmonary tuberculosis
• Every case should be categorised as RNTCP guidelines.
• Treatment should be given as per case categories
• Patient who is intolerant to Rifampicin may be given Non-
DOTS I & II
• Follow up is done at 2,4,and 6 months in Cat-I and 2,5, and 8
month in Cat-II DOTS
• Cat-III DOTS is now removed from RNTCP and all patients
previously belonging to this category are now shifted to Cat-I
DOTS
53. QUESTIONS
• Prescribe an appropriate antitubrculosis regimen based on location of
disease, smear positivity and negativity and co-morbidities based on
current national guidelines including directly observed tuberculosis
therapy (DOTS)
• RNTCP strategy for prevention and control of TB
