Tuberculosis

Tuberculosis (TB) is a chronic bacterial infection that primarily affects the lungs caused
by tubercle bacillus (Mycobacterium tuberculosis). When affecting the lungs the
disease is referred to as pulmonary TB, disseminated TB (or extrapulmonary TB) refers
to other areas of the body if the bacilli infection has spread (Jardins & Burton, 2006).
The

disease

can

infect

humans

via

three

transmission

routes:

respiratory,

gastrointestinal and through open wounds. The most common route of contraction is
through inhalation of tubercle bacillus contained in aerosol droplets from an infected
individual (Jardins et al., 2006). The primary infection stage follows when the patient is
first exposed to the pathogen, this inflammatory response causes an influx of fluid
leukocytes and macrophages causing consolidation. This is followed by the encasing of
the bacillus pathogen and macrophages by a tubercle formed from fibroblasts,
lymphocytes and neutrophils (Jardins et al., 2006). This housing acts to prevent further
infection but also has negative associations as the center may become necrotic
leading to caseous lesions which occurs within 2 to 4 weeks (Frownfelter & Dean,
2012).
TB is a chronic restrictive pulmonary disorder that causes major pathological and
structural damage to the lungs. Symptoms include: alveolar consolidation, caseous
tubercles or granulomas, fibrosis when the tubercle heals (Frownfelter et al., 2012).
The effects of tuberculosis on pulmonary function vary, if there is lung tissue
involvement it can reduce lung volumes, hypoventilation and compromise arterial
blood gas levels. Fibrosis will reduce long compliance and may restrict airflow if
bronchioles become narrow or distorted, this leads to increased respiratory muscle
activation in order to expand the lungs for gas exchange. Pleural infection is also a
possibility causing restriction which can be the source of effusions, empyema or
pneumothorax. Generally the patient adopts a rapid, shallow breathing pattern leading
to dead space from the infection becoming hyperinflated and alveoli being
hypoinflated (Frownfelter et al., 2012; Wilches, Rivera, Mosquera, Loaiza, & Obando,
2009). This coupled with the lung damage impairs the ventilation-perfusion ratio and
consequently the capability of gas exchange.
The objective of a physiotherapist in the treatment of TB is to aid in improving this
impairment to maximise respiratory efficiency by both increasing ventilation and
moving secretions. The clinical presentation of TB includes: coughing, fever, weight
loss, fatigue and haemoptysis, this must being taken into consideration when
implementing physiotherapy treatments (Frownfelter et al., 2012). There are some
chest physiotherapy techniques that are contraindicated during the active stage of
tuberculosis due to possibility of infection being spread further within the lung, these
include: percussion, shaking and vibrations (Frownfelter et al., 2012; Mitra, 2007). For
this reason techniques such as postural drainage, autogenic drainage and breathing
exercises are more effective as they ensure patient condition does not deteriorate. In
William Morrissey

PS2002

Presentation

terms of fibrosis after the active stage of TB has gone into remission, deep breathing
and breath hold exercises are used in order to stretch the tissue to retain lung
compliance (Mitra, 2007).

A physiotherapists role when treating TB also includes

maintaining exercise tolerance and working as part of a multidisciplinary team to

ensure the patient receives the best possible care available.

References

Frownfelter, D., & Dean, E. (2012). Cardiovascular and Pulmonary Physical Therapy
Evidence to Practice (5 ed.). St. Louis, Missouri: Elsevier.
Jardins, T. D., & Burton, G. G. (2006). Clinical manifestations and assessment of
respiratory disease (5 ed.). St. Louis, Missouri: Elsevier.
Mitra, P. K. (2007). Handbook of Practical Chest Physiotherapy (Vol. 1). New Delhi,
India: Jaypee Brothers Medial Publishers.
Wilches, E. C., Rivera, J. A., Mosquera, R., Loaiza, L., & Obando, L. (2009). Pulmonary
rehabilitation in multi-drug resistant tuberculosis (TB MDR): a case report.
Colombia Medica, 40(4).

William Morrissey

PS2002

Presentation

TREATMENT TUBERCULOSIS

Wash hands, gown, mask and gloves, check bed breaks

Check obs
o Blood pressure (MAP = diastolic + 1/3(systolic diastolic)): 65<x<100 is
alright
o HR: 60 72 is normal, if not in 50<x<140 use caution
o ABG
pH
7.35 7.45 low is acidosis, high alkalosis
PaO2 80 100 (mmHg) indicate if hypoxic
PaCO2
35 45 (mmHg)
low causes resp. alka., high
causes resp. acid
HCO3-22 28 (mmol/l)
low causes metabolic acid, low alka
BE
-2 - +2 (mmol/l)
o O2 saturation: 96% normal, should not fall below 92% during
interventions unless that is normal for patient or if position is causing.
ABG better indicator
o Platelets: 150 400 x 10^9 normal, >75 no restriction to treatment
o Haemoglobin
Male: 13 18 gm/dL (130 180 g/cL) care below 85
Female: 12 16 gm/dL (120 160 g/cL) care below 85
Clear contraindications and precautions for each treatment
Difficulty breathing
Explanation, warning, questions, understand, consent
Incentive spirometer encourage deep breathing, visual feedback
Postural drainage: 20mins one position, 5mins per position if multiple
o Upper lobe
Apical sitting upright
Posterior Right left side lying toward prone pillow under
shoulder
Posterior left right side lying off prone, 3 pillows to raise
shoulder 30cm
Anterior supine pillows under knees
o Lingula (left lung only)
Superior/inferior supine turned to R. pillow under shoulder to
hip. Tilt 15 head down
o Middle lobe (right lung only)
Lateral/medial head down 15. Supine 1.4 turned to left. Pillow
hip to shoulder
o Lower lobe
Apical prone pillow under abdomen
Anterior supine with knees flexed. Head down 20
Medial head down 20 side lying (eg. left side lying for right
drainage)

William Morrissey

PS2002

Presentation

Lateral head down 20 side lying (same as medial, opposite lobe

medial will also drain)
Posterior head down 20 prone, pillow under hips
Active cycle of breathing help mobilise secretions, can be used with postural
drainage
o 30s controlled breathing, 4-5 deep breaths, 30s controlled breathing, 2-3
deep breaths, 1-2 huffs, 30s controlled breathing then huff or cough to
clear secretions

William Morrissey

PS2002

Presentation