Critical Conditions in Pulmonary Tuberculosis in Adults - N.I. Fomichova 2010

Classification of Critical Conditions in Pulmonary Tuberculosis

Tuberculosis is a chronic infectious disease characterized by diverse tissue reactions. At the onset of the disease, an inflammatory process develops in The Human Body with all its inherent features. Subsequently, the inflammation acquires specific traits, predominantly featuring a productive tissue reaction with granuloma formation, caseous necrosis, and a tendency toward a chronic course. The latter is marked by The Development of fibrosis, circulatory Changes in the pulmonary circuit, and impaired functional status of the Lungs and Cardiovascular system, eventually leading to hypercapnia, Hypoxia, and hypoxemia, which in turn cause profound Metabolic Disorders.

Therefore, in a patient suffering from tuberculosis, a critical condition requiring intensive therapy and sometimes emergency resuscitation care may develop at any stage of the disease course.

In adults with respiratory tuberculosis, critical conditions of various pathogeneses may occur. The most frequent among them include hemoptysis, Pulmonary Hemorrhage, intrapleural hemorrhage, Spontaneous pneumothorax, acute respiratory and Heart Failure, pulmonary edema, pulmonary infarction, thrombosis and Pulmonary Embolism, disseminated intravascular coagulation (DIC) syndrome, Atelectasis, asphyxia, anaphylactic Shock, anti-tuberculosis Drug poisoning, and Intoxication syndrome. The development of a critical condition is primarily triggered by corresponding pathomorphological changes in the lungs, Bronchi, Pleura, and the tuberculosis patient's body as a whole. Understanding the mechanisms underlying the development of a particular emergency condition in respiratory tuberculosis enables physicians to predict the likelihood of its occurrence in each specific clinical case and provides the opportunity to deliver timely medical assistance.

Thus, based on The Nature of pathomorphological changes capable of precipitating various critical conditions in respiratory tuberculosis, the latter can, in our opinion, be classified as follows:

I. Specific inflammation without caseous-destructive changes in the lungs.

1. Hemoptysis.

II. Caseous-destructive processes in the lung tissue.

1. Pulmonary hemorrhage, hemoptysis.

2. Intrapleural hemorrhage.

3. Spontaneous pneumothorax.

4. Intoxication syndrome.

5. Acute heart failure.

6. Acute Respiratory Failure.

7. Atelectasis.

III. Compression and obstruction of the Airways.

1. Atelectasis.

2. Asphyxia.

3. Acute respiratory failure.

IV. Fibrotic, bullous-dystrophic, and cirrhotic changes in the lungs and pleura.

1. Pulmonary hemorrhage, hemoptysis.

2. Pulmonary embolism.

3. Spontaneous pneumothorax.

4. Acute respiratory failure.

5. Acute heart failure.

According to the nature of functional changes:

I. Circulatory Disorders in the lesser (pulmonary) Circulation.

1. Pulmonary hemorrhage, hemoptysis.

2. Pulmonary embolism.

3. Acute respiratory failure.

4. Acute heart failure.

II. Impairment of respiratory function.

1. Acute respiratory failure.

2. Acute heart failure.

Based on the severity of the clinical course and the specific requirements for medical care,

critical conditions should be divided into 3 stages. The First stage is the prodromal stage. The patient's general condition is of moderate severity, but it is prone to deterioration. This category includes patients with Pulmonary Tuberculosis accompanied by moderately severe intoxication, patients with hemoptysis, Chronic Cor Pulmonale in the subcompensation stage, and limited spontaneous pneumothorax. Such patients require hospitalization, continuous medical supervision, continuation of primary disease Treatment, and the prescription of additional therapeutic measures due to the onset of complications. The Second Stage comprises patients requiring emergency care and intensive therapy. This stage includes patients with dyspnea due to prolonged bronchospasm, laryngeal edema, stage II–III respiratory failure, development of acute cor pulmonale, grade II–III pulmonary hemorrhage, spontaneous pneumothorax, pulmonary infarction, antituberculosis drug poisoning, and pronounced intoxication syndrome (Caseous Pneumonia, miliary or disseminated tuberculosis, Tuberculous meningitis, etc.). These patients require hospitalization and emergency medical care. The Third Stage includes patients who need resuscitation measures. Such conditions may occur in tension spontaneous pneumothorax, profuse pulmonary hemorrhage, significant intrapleural hemorrhage, pulmonary edema, and pulmonary thrombosis and embolism.

The development of critical conditions in adults with respiratory tuberculosis is directly dependent on the form and phase of the tuberculous process, that is, on the nature of pathomorphological and functional changes. Given this, all patients can, in our opinion, be divided into 6 categories.

Category I – recent, limited tuberculous process without destructive changes (focal, infiltrative, disseminated). Such forms of tuberculosis are most frequently accompanied by the development of:

✵ hemoptysis.

Category II – recent, extensive tuberculous process with the presence of destruction (infiltrative, disseminated tuberculosis, caseous pneumonia, Tuberculoma). Such forms of tuberculosis are most frequently accompanied by the development of:

✵ intoxication syndrome,

✵ hemoptysis, pulmonary hemorrhage,

✵ intrapleural hemorrhage,

✵ spontaneous pneumothorax,

✵ atelectasis,

✵ acute heart failure,

✵ acute respiratory failure.

Category III – chronic destructive forms of tuberculosis in the exacerbation stage (fibro-cavitary, chronic disseminated). Such forms of tuberculosis are most frequently accompanied by the development of:

✵ intoxication syndrome,

✵ pulmonary hemorrhage, hemoptysis,

✵ spontaneous pneumothorax,

✵ acute respiratory failure,

✵ acute heart failure.

Category IV – chronic forms of tuberculosis in remission (chronic disseminated, fibro-cavitary, and cirrhotic tuberculosis). Such forms of tuberculosis are most frequently complicated by:

✵ acute respiratory and heart failure,

✵ Pulmonary Hemorrhage and Hemoptysis,

✵ pulmonary embolism,

✵ spontaneous pneumothorax.

Category V – residual post-tuberculosis pulmonary changes (bullous-dystrophic and cirrhotic changes, pleural adhesions, residual cavities). Such conditions most commonly lead to:

✵ acute respiratory failure,

✵ acute heart failure,

✵ spontaneous pneumothorax,

✵ pulmonary hemorrhage, hemoptysis.

Category VI – patients with extrapulmonary respiratory tuberculosis, such as Tuberculosis of the Larynx, bronchi, and intrathoracic Lymph Nodes. These conditions most frequently result in:

✵ acute respiratory failure,

✵ hemoptysis,

✵ asphyxia, atelectasis.

Emergency conditions caused by the administration of anti-tuberculosis drugs may develop in patients across all categories:

✵ anaphylactic shock,

✵ poisoning / drug toxicity.