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ASCENDING SPONTANEOUS PNEUMOTHORAX, PTB III- 1, SEVERE MALNUTRITION

NTRODUCTION
Pulmonary tuberculosis is an infectious disease caused by slow- growing bacteria that
resembles a fungus, Myobacterium tuberculosis, which is usually spread from person to
person by droplet nuclei through the air. The lung is the usual infection site but the
disease can occur elsewhere in the body. Typically, the bacteria from lesion (tubercle) in
the alveoli. The lesion may heal, leaving scar tissue; may continue as an active
granuloma, heal, then reactivate or may progress to necrosis, liquefaction, sloughing,
and cavitation of lung tissue. The initial lesion may disseminate bacteria directly to
adjacent tissue, through the blood stream, the lymphatic system, or the bronchi.
Most people who become infected do not develop clinical illness because the body’s
immune system brings the infection under control. However, the incidence of
tuberculosis (especially drug resistant varieties) is rising. Alcoholics, the homeless and
patients infected with the human immunodeficiency virus (HIV) are especially at risk.
Complications of tuberculosis include pneumonia, pleural effusion, and extrapulmonary
disease.
ANATOMY AND PHYSIOLOGY

UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers to the act of
breathing, or inhaling and exhaling. Biologically speaking, respiration strictly means the
uptake of oxygen by an organism, its use in the tissues, and the release of carbon
dioxide. By either definition, respiration has two main functions: to supply the cells of the
body with the oxygen needed for metabolism and to remove carbon dioxide formed as a
waste product from metabolism. This lesson describes the components of the upper
respiratory tract.
The upper respiratory tract conducts air from outside the body to the lower respiratory
tract and helps protect the body from irritating substances. The upper respiratory tract
consists of the following structures:
The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper
trachea. The oesophagus leads to the digestive tract.
One of the features of both the upper and lower respiratory tracts is the mucociliary
apparatus that protects the airways from irritating substances, and is composed of the
ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a
layer of mucus that traps unwanted particles as they are inhaled. These are swept
toward the posterior pharynx, from where they are either swallowed, spat out, sneezed,
or blown out.
Air passes through each of the structures of the upper respiratory tract on its way to the
lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth.
The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like
structure that connects the back of the nasal cavity and mouth to the larynx, a
passageway for air, and the esophagus, a passageway for food. The pharynx serves as
a common hallway for the respiratory and digestive tracts, allowing both air and food to
pass through before entering the appropriate passageways.
The pharynx contains a specialised flap-like structure called the epiglottis that lowers
over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract.
The larynx, or voice box, is a unique structure that contains the vocal cords, which are
essential for human speech. Small and triangular in shape, the larynx extends from the
epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition,
the larynx has specialised muscular folds that close it off and also prevent food, foreign
objects, and secretions such as saliva from entering the lower respiratory tract.
LOWER RESPIRATORY TRACT
The lower respiratory tract begins with the trachea, which is just below the larynx. The
trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped
cartilage in its walls. The inner portion of the trachea is called the lumen.
The first branching point of the respiratory tree occurs at the lower end of the trachea,
which divides into two larger airways of the lower respiratory tract called the right
bronchus and left bronchus. The wall of each bronchus contains substantial amounts of
cartilage that help keep the airway open. Each bronchus enters a lung at a site called
the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi.
The tertiary bronchi branch into the bronchioles. The bronchioles branch several times
until they arrive at the terminal bronchioles, each of which subsequently branches into
two or more respiratory bronchioles.
The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-
like, elastic, thin-walled structures that are responsible for the lungs’ most vital function:
the exchange of oxygen and carbon dioxide.
Each structure of the lower respiratory tract, beginning with the trachea, divides into
smaller branches. This branching pattern occurs multiple times, creating multiple
branches. In this way, the lower respiratory tract resembles an “upside-down” tree that
begins with one trachea “trunk” and ends with more than 250 million alveoli “leaves”.
Because of this resemblance, the lower respiratory tract is often referred to as the
respiratory tree.
In descending order, these generations of branches include:
 trachea
 right bronchus and left bronchus
  secondary bronchi
 tertiary bronchi
 bronchioles
 terminal bronchioles
 respiratory bronchioles
 alveoli
THE LUNGS

The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two
lungs that occupy a significant portion of this cavity.
The diaphragm is a broad, dome-shaped muscle that separates the thoracic and
abdominal cavities and generates most of the work of breathing. The inter-costal
muscles, located between the ribs, also aid in respiration. The internal intercostal
muscles lie close to the lungs and are covered by the external intercostal muscles.
The lungs are cone-shaped organs that are soft, spongy and normally pink. The lungs
cannot expand or contract on their own, but their softness allows them to change shape
in response to breathing. The lungs rely on expansion and contraction of the thoracic
cavity to actually generate inhalation and exhalation. This process requires contraction
of the diaphragm.
To facilitate the movements associated with respiration, each lung is enclosed by the
pleura, a membrane consisting of two layers, the parietal pleura and the visceral pleura.
The parietal pleura comprise the outer layer and are attached to the chest wall. The
visceral pleura are directly attached to the outer surface of each lung. The two pleural
layers are separated by a normally tiny space called the pleural cavity. A thin film of
serous or watery fluid called pleural fluid lines and lubricates the pleural cavity. This fluid
prevents friction and holds the pleural surfaces together during inhalation and
exhalation.
PREDISPOSING FACTORS
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle
5. Virulence
6. Over fatigue
SIGNS AND SYMPTOMS
1. Productive Cough – yellowish in color
2. Low fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, weight loss
6. Chest/back pain
7. Hemoptysis
PATHOPHYSIOLOGY
DIAGNOSTIC EVALUATION
 Sputum smear – detection of the acid fast bacilli in stained smears is the first
bacteriologic clue of TB. Obtain first morning sputum on 3 consecutive days.
 Sputum culture – a positive culture for M. tuberculosis confirms a diagnosis of
TB.
 Chest X-ray – to determine presence and extent of disease.
 Tuberculin skin test (purified protein derivative or Mantoux test)
– inoculation of tubercle bacillus extract (tuberculin) into the intradermal layer of the
inner aspect of the forearm.
 Nonspecific screening test – such as multiple puncture tests (tine test), should
not be used to determine if a person is infected.
MEDICATION
♦A combination of drugs to which the organisms are susceptible is given to
destroy viable bacilli as rapidly as possible and to protect against the
emergence of drug resistant organism.
♦Current recommended regimen of uncomplicated, previously untreated
pulmonary tuberculosis is an initial phase of 2 months of bacterial drugs,
including isoniazid (INH), rifampin ( Rifadin), pyrazinamide (PZA), and
ethambutol (EMB). This regimen should be followed until the results of
drug susceptibility studies are available, unless there is little possibilityn of
drug resistance.
a. If drug susceptibility results are known and organism is fully susceptible,
ethambutol does not need to be included.
b. For children whose visual acuity cannot be monitored, ethambutol is not
normally recommended except with increased likelihood of isoniazid
resistance or if the child has upper lobe infiltration and or cavity
formation of TB.
c. Due to increasing frequency of global streptomycin reistance,
streptomycin is not considered interchangeable with ethambutol unless
organism is known to be susceptible to streptomycin.