Master in Pediatric Nursing

1. Pulmonary Tuberculosis
ANU CHALISE
MN,NAMS

2. Introduction
• Pulmonary Tuberculosis is an infectious disease of the lungs
parenchyma caused by mycobacterium tuberculosis .
• Pulmonary parenchyma is the most common site of infection.
• Other parts of the body like kidney ,meninges, bones, lymph nodes,
skin can be infected.

3. Epidemiology
• Worldwide, TB is one of the top 10 causes of death and the leading cause
of a single infectious agent (above HIV/AIDS).
• Globally, nearly 10 million population developed TB in 2017 and TB
caused an estimated 1.3 million deaths (including 0.3 million among people
with HIV) in the same year, making TB one of the leading cause of deaths
for HIV-positive people.
• There were cases in all countries and age groups, but overall 90% were
adults (aged ≥15 years) and 64% of them were males, 9% were people
living with HIV.
• South East Asia Region alone holds nearly 45 % of global TB cases.
• Almost 10% of TB is still among the children.
• Because diagnosing and reporting of TB in children has always been
difficult and faces lots of technical and programmatic challenges.

4. • WHO’s list of 30 high TB burden countries accounted for 87% of the
world’s cases with India alone holding nearly 27% of cases followed by 9%
of cases in China.
• One of key factor contributing to TB is smoking tobacco, which nearly
increases the risk of TB by two and half times.
• More than 20% of global TB incidence may be attributable to smoking.
Controlling the tobacco epidemic will help control the TB epidemic.
• By 2020, the TB incidence rate (new cases per 100 000 population per
year) needs to be falling at 4–5% per year, and the proportion of people with
TB who die from the disease (the case fatality ratio, CFR) needs to fall to
<=5%.
• The disease burden caused by TB is falling globally but not fast enough to
reach the first (2030) milestones of the End TB.

5. • MDR-TB remains a public health crisis and a health security threat. In
2017, WHO estimates that there were 558,000 new cases with
resistance to rifampicin, the most effective first-line drug of which
82% had MDR-TB.
• About 1.7 billion people, 23% of the world’s population, are
estimated to have a latent TB infection, and are thus at risk of
developing active TB disease during their lifetime.

6. Nepal:
• In 2017/18, a total of 32,474 cases of TB were notified and registered at
NTP.
• TB case notification, as well as estimated incidence, has been stagnant for
more than decades now in Nepal (CNR 152/100,000 in 2018) despite best
efforts of the program is trying to find and cure more TB cases.
• TB cases were reported from all parts of the country, but the Flat/Terai belt
reported the highest numbers of cases followed by hills and mountains.
• The childhood TB cases reported are nearly 5.5% of all cases which is still a
huge challenge in Nepal.
Note: Case notification rate (CNR)

7. • Among the reported cases, men are nearly 1.7 times as compared to
women cases (M:F = 1.7:1).
• Nepal TB program is also missing out to find nearly 28% of estimated
cases annually, which has played a big role in control of TB program
with 20-25% among them estimated to be held and unreported by
private sector.

8. Sustainable Development Goal
Goal 3: Good health and wellbeing- Ensure healthy lives and promote
wellbeing for all at all ages.
Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria
and neglected tropical diseases and combat hepatitis, waterborn
diseases and other communicable diseases.

9. The National TB strategy 2016 to 2021
Vision:
• To end the TB by 2030 and make Nepal free of TB by 2050 in accordance
with the National Health Policy 2014 and under the strategic direction of the
worldwide initiative to end TB –The End TB Strategy.
• Ending TB is defined as a decrease in incidence rate of more than 80% by
2030 and 90% by 2035 compared to 2015 baseline.
• It is believed that a rapid expansion of the quality TB care services leading
to increased access and effective implementation of the program through
responsible and integrated health system, intensified case finding and using
appropriate preventive measures will help achieve the vision.

10. Goal
• To decrease the TB Incidence Rate by 20% by 2021 as compared to
2015.

11. DOTS (Directely Observed Treatment Short course)
• Successfully implemented since 2001
• 1440 DOTS treatment centers and 2907 sub centers are established till 16th July
2014
• Success rate: 89% and case finding rate of 83% in the year 2070/71
Source of infection:
Infected adult in the close environment . Young children below 10 are at risk of
becoming infected with TB bacilli because the immune system of young children is
less developed .
In HIV infected children : High risk of developing TB. TB and malnutrition often
go together and a child with TB may present as failure to gain weight with loss of
energy and cough for more than 3 weeks.

12. Causative Organisms
• Rod shaped ,aerobic bacterium ‘Mycobacterium tuberculosis “.
• Acid fast bacilli and is heat sensitive to heat ultraviolet (UV) light .
• Cell wall is key to the survival M.bovis and M.Avium.
Transmission :
small airborne droplets called droplet nuclei ,generated by the coughing
,sneezing ,talking of a person with infection.
Spread to other organs ,such as the lymphatics ,pleura ,bones /joints , or
meninges and cause extra pulmonary tuberculosis.

13. Droplet Transmisson

14. Risk Factors
• Close contact with infected person
• Age ; infants and adolescents
• Poor nutritional status
• Suffering from infection like HIV, measles ,pertussis ,whooping cough
• Stressful situation like injury ,illness ,emotional distress.

15. Pathology
• Inhalation of Bacilli
• Multiplication in Pulmonary alveoli
• Inflammation with hyperemia and Congestion occur
• as well as polymorphonuclear leukocytes(neutrophils, eosinophils and
basophils) is infiltrated at the site of lesion
• Pulmonary alveoli filled with exudates ,comprising of fibrin, leukocytes ,
Phagocytes and tubercle bacilli.
• Phagocytes surround the bacteria and engulf them.
• A granulomatous leison that is sealed off colony of bacilli called ghon
tubercle is formed.
• within the ghon tubercle infected tissues necrose forming cheese like center
which is called cessation necrosis

16. Lungs Infected with Tuberculosis

17. • When this ghon tubercle is ruptured, lots of bacteria are exposed and spread.
Some bacteria enter the lymphatic system to stimulate cell mediated
immune response.
• If adequate immune response , scar tissue develops around tubercle and the
bacilli remains encapsulated and lesion calcify and visible on X-ray
• Adequate immune response: child does not develop TB but if immunity is
impaired ,TB develops.
• Late manifestations: extensive destruction of lung tissue, erosion of blood
vessels and spread throughout lung and other organs. Hemoptysis occur.

18. Clinical Manifestations
Stages include latency, primary disease, primary progressive disease and
extrapulmonary disease.
1.Latent Tuberculosis:
No signs and symptoms and are not infectious .
However, viable bacilli can persist in the necrotic material for years or even a
lifetime and if immune later becomes compromised disease is reactivated .
2.Primary progressive Tuberculosis:
Develop in only 10% of persons exposed to M. bacilli. Early signs and
symptoms are often non specific

19. • Progressive fatigue , malaise ,weight loss and low grade fever accompanied
by chills and night sweats for more than 2weeks.
•Wasting : lack of appetite and altered metabolism associated with
inflammatory response. Decreased mass contributes to fatigue.
•Cough:>3wks duration. Initially non productive later advances to productive
(Purulent type)
•Hemoptysis: Destruction of vessels located in the walls of cavity.
•Pleuritic chest pain : Due to Inflammed parenchyma
•Dyspnea or Orthopnea: Due to increased interstitial volume leading to
decrease in lung diffusion capacity.
•Rales : often over involved area during inspiration
•Hematologic study: Anemia, Increased ESR and Leukocytosis.

20. 3. Extra pulmonary Tuberculosis:
• Occur in more than 20% of patients and and incidence increases with
immunosuppression.
• Central nervous system: most serious because of resulting meningitis and
space-occupying tuberculomas.
• Miliary tuberculosis : Another fatal form
• Lymphatic tuberculosis : Most common extrapulmonary tuberculosis and
cervical adenopathy occurs most often.
Other possible locations: Bones, Joints, Pleura and genitourinary system.

21. Diagnostic Investigation
Difficult in young child because they cannot cough up enough sputum for
laboratory investigations.
• History: Contact history, symptoms consistent with TB
• Clinical examination including growth assessment
• Mantoux test ( Tuberculin Skin testing ): Intradermal Tuberculin Purified
Protein Derivative (PPD) is used and result observed after 48-72 hours.
 High-risk children (HIV infected and severely malnourished ): TST
≥5mm induration
All other children: TST ≥ 10 mm induration is regarded as positive
regardless of BCG vaccination.
Value of Test: Positive test indicates infection but not necessarily indicate
disease.

22. Treatment :
Drug ( anti-tuberculosis drug ) therapy :
• Similar to adult but doses in children per kilogram body weight should be
higher due to higher metabolism.
• Note: children develop extra pulmonary TB more often than adult do.
Treatment regimen identify three groups
1.Those with sputum smear negative disease
2.Those with sputum smear positive disease(Often cavitary)
3.Those with disseminated (miliary) disease.

24. Treatment

28. Special Situations
• A pregnant woman should be advised that successful treatment of TB with the
standard regimen is important for successful outcome of pregnancy. The first line
anti-TB drugs are safe for use in pregnancy.
• Breast feeding mother should be given normal full course of TB treatment.
Timely and properly applied chemotherapy is the best way to prevent transmission
of tubercle bacilli to the baby.
• Mother and baby should stay together, and the baby should continue to breastfeed.
Use mask while brestfeeding and practice other infection control measures.
• After active TB in the baby is ruled out, the baby should be given 3 months RH
preventive therapy, followed by BCG vaccination.
• Pyridoxine 10 mg daily supplementation is recommended for all pregnant or
breastfeeding women taking isoniazid (INH) throughout the TB treatment

29. General management:
a. Isolation: Keep in negative –pressure room, advise patient to cover nose and
mouth with tissue while coughing and sneezing, restrict too many visitors to sit with
child and ask them to wear masks. Child must wear mask while going out of room.
b. Nutrition: Adequate nutrition must be provided for child because malnutition
increases the risk of tuberculosis and helps in disease progression.
c. Rest: Initially keep the patient in bed rest than gradually increase the activity of
child according to tolerance of child.
d. Emotional support and Education: Allow patient and visitors to express their
feelings, answer their queries, educate them about the transmission of disease and
treatment. Promote patient compliance to treatment, educate about nutrition, activity
and rest.

30. Nursing Management :
1. Assessment :
clinical features, comlications of TB , its treatment and readiness for
therapy
2. Nursing Diagnosis:
•Ineffective airway clearance
•Impaired gas exchange
•Imbalanced nutrition
•knowledge deficit about disease

31. 3.Nursing Intervention:
• Promoting airway clearance :
Fluid intake, Positioning, Airway drainage
• Promote effective gas exchange: admister oxygen, positioning,
antibiotics
• Promote/maintain adequate rest and activity
• Plan a progressive activity schedule focussing on increasing activity
tolerance and muscle strength.

32. 3. Nursing Intervention…..
•To fight against anorexia,weight loss and malnutrition, promote high quality
nutritional supplement (Frequent small nutritious meal and adequate
hydration )
• Advocate need for adherence to treatment regimen (child and parents)
• Parent and child instruction for regular and complete course of treatment
• Prevention of infection Spread: Isolation until AFB negative
• Preventing/monitoring/manage potential complication: Malnutrition, side
effects of medications, hemoptysis
• Involve child and family in care of the child
• Teach /Instruct child and family about needed self care at home like
nutrition, hydration, medication, followup, rest ,precautions etc.

33. Comlications :
Extrapulmonary (miliary) TB, malnutrition, multidrug resistance
(MDR) TB , hemoptysis, Pleurisy

34. Prevention of TB disease in children:
• Early diagnosis and successful treatment of an infectious adult patient
is the best way to protect children.
• BCG immunization soon after birth upto 2 year: prevent TB
meningitis
• Chemoprophylaxis: Prevention of breast feeding infants whose
mothers are sputum positive .
Isoniazed 5-10 mg /kg for 6-9 months.

35. References
1.Hockenberry, M. & Willson, D. (2015). Wong's Essential of pediatric
Nursing (8th ed.). New Delhi, India: Elsevier India PVT.
2.Ghai, O. P., Paul, V. k., & Bagga, B. (2010). Essential Padiatrict (7th ed.),
New Delhi, India: Thomas press India PVT, Ansari Road.
3.Dutta, P. (2010). Pediatric Nursing (2nd ed.). New delhi, India: Jypee
publisher
4.Marlow R Dorathy & Rediing A. Barbara (2010,) Text book of pediatric
Nursing ( 6th edition) , Elsevier India PVT , New Delhi

36. 5. Shrestha, T. (2012). Essential Child Health Nursing. (1st ed.).
Kathmandu: Medhavi Publication.
6. Uprety, K. (2018). Essential of Child Health Nursing. (1st ed.).
Kathmandu: Tara Books and stationary.
7. Government of Nepal.(2019). National Tuberculosis Management
Guideline, National Tuberculosis Centre, Thimi, Bhaktapur.