Tuberculosis, thoracoplasty and post-TB lung disease

1Definition

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, spread through the air when a person with lung TB coughs. It mainly affects the lungs (pulmonary TB) but can affect any organ.

Post-TB lung disease is lasting lung damage after TB is cured: fibrosis, cavities, bronchiectasis, airway narrowing, pleural thickening or a destroyed lung (one lung or lobe almost completely destroyed).

Thoracoplasty is an operation that removes parts of several ribs so the chest wall collapses inwards onto a diseased lung or an infected space. Once used to treat TB, it is now rare and used mainly for chronic empyema spaces.

2Classification

• Latent TB infection: infected but no disease and not infectious.
• Active pulmonary TB: primary (children) or post-primary (reactivation in adults, usually in the upper lobes with cavities).
• Extrapulmonary TB: pleura (TB effusion), lymph nodes, spine (Pott's disease), meninges, abdomen.
• Drug-sensitive or drug-resistant (MDR-TB resists the two main drugs).
• Post-TB sequelae: bronchiectasis, fibrosis with volume loss, destroyed lung, aspergilloma in an old cavity, chronic obstruction.

3Risk factors

• Close contact with an infectious patient; crowded, poorly ventilated housing.
• Undernutrition, diabetes, HIV, smoking, alcohol, silicosis, steroids or other immune suppression.
• Delayed diagnosis or incomplete treatment (risk of drug resistance and lung damage).

4Pathophysiology to impairments

1. Inhaled bacilli cause granulomas; in active disease the centre breaks down (caseation) and is coughed out, leaving cavities.
2. Healing is by fibrosis, which shrinks the lobe, pulls the trachea and mediastinum to that side and distorts the airways (traction bronchiectasis).
3. Damaged airways cannot clear mucus, so the vicious cycle of bronchiectasis begins (see the bronchiectasis page).
4. Restriction (fibrosis), obstruction (airway damage) or both reduce exercise capacity; severe damage causes low oxygen and right heart strain.
5. After thoracoplasty: chest wall deformity, loss of ribs, paradoxical movement early on, and later scoliosis and shoulder problems on the operated side.

5Clinical features

• Active TB: cough for more than 2 weeks, sputum, haemoptysis, evening fever, night sweats, weight loss, loss of appetite, fatigue.
• Post-TB lung disease: chronic cough with sputum, breathlessness, recurrent infections, haemoptysis, reduced chest expansion and flattening over the affected side, tracheal shift towards it.
• Destroyed lung (S22): breathlessness, chest pain, fever and cough with infective exacerbations.

6Investigations

• Sputum tests: rapid molecular test (for example CBNAAT/Xpert, also detects rifampicin resistance), smear microscopy, culture.
• Chest X-ray: upper-lobe infiltrates, cavities, fibrosis with volume loss, calcification; tracheal shift; destroyed lung appears opaque and shrunken.
• CT for post-TB damage; spirometry (obstructive, restrictive or mixed); SpO₂, ABG, 6MWT.
• HIV and diabetes testing.

7Medical and surgical management

• Drug-sensitive TB (NTEP, India): about 6 months of daily fixed-dose combination tablets: an intensive phase with four drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months, then a continuation phase (isoniazid, rifampicin, ethambutol) for 4 months.
• Drug-resistant TB needs longer, specialised regimens.
• Treatment support, nutrition support (Ni-kshay Poshan Yojana), contact tracing.
• Surgery for complications: lobectomy or pneumonectomy for destroyed lung or aspergilloma; decortication for empyema; thoracoplasty for chronic spaces.

8Complications and prevention

• Haemoptysis (can be massive), pneumothorax, empyema, bronchiectasis, aspergilloma, respiratory failure, cor pulmonale.
• Drug side effects: liver injury, peripheral neuropathy (isoniazid), visual problems (ethambutol), joint pain.
• Post-thoracoplasty: scoliosis, shoulder stiffness, chest infection, paradoxical chest movement.

9PT assessment

• Infectious status (on treatment how long? sputum results?), treatment adherence, nutrition and weight.
• Cough, sputum amount and colour, haemoptysis, breathlessness (mMRC), fever.
• Chest shape, expansion, tracheal position, auscultation; posture and spine; shoulder range (after thoracoplasty).
• SpO₂ at rest and on exercise; 6MWT; muscle strength.
• Work and home: crowding, ventilation, smoke exposure, earning role.
• Outcome measures: 6MWT, mMRC, St George's Respiratory Questionnaire, weight.

10PT diagnosis by ICF

Worked example from a real paper (S22, 15 marks)

"A 45 year old farmer, diagnosed case of destroyed lung secondary to tuberculosis. He complains of shortness of breath, chest pain, fever and cough since 4 days. Write functional diagnosis, goals and physiotherapy management in detail."

How the S24 case differs (25-year-old student, right destroyed lung)

• Clues: crackles over the right upper chest (secretions), pain on deep breathing and coughing on the right (pleural involvement), HR 105 and RR 28 (fast and shallow breathing at rest), FEV1 60% and FVC 56% predicted (both reduced by a similar amount: a mainly restrictive loss of lung volume).
• Participation: a student who cannot run or play sport, so his goals are studies, sport and fitness rather than farm work.
• Plan: pain relief and supported breathing; ACBT with the right upper lobe drained in sitting; thoracic expansion of the left lung and the healthy parts of the right; then pulmonary rehabilitation with interval training and strengthening, aiming at a graded return to sport; infection control and completion of TB follow-up.

11Problem list and goals

• Short-term (1–2 weeks): clears sputum independently; breathlessness controlled with breathing control and positioning; walks in the ward with stable SpO₂.
• Long-term (2–3 months): completes pulmonary rehab; better 6MWT and mMRC; returns to lighter farm work with pacing and a mask; fewer exacerbations.

12PT management

During an exacerbation or active disease

• Airway clearance (ACBT, autogenic drainage, PEP devices) in positions that drain the affected area; avoid head-down tilt with haemoptysis.
• Breathing control, relaxation, positioning to ease breathlessness. For gas exchange, lie with the better lung down when one lung is destroyed.
• Pain relief and supported coughing for pleuritic pain.
• Early mobilisation as fever settles; hydration and nutrition advice.

Pulmonary rehabilitation for post-TB lung disease

• Endurance and strength training as in COPD (6–12 weeks, 2–3 supervised sessions a week), with oxygen if SpO₂ falls on exercise.
• Daily airway clearance routine; inspiratory muscle training if weak.
• Thoracic mobility and posture exercises; energy conservation for farm and household work.
• Education: complete TB treatment, recognise relapse, nutrition, smoking cessation, dust protection.

After thoracoplasty (W18 nurse, day 2)

• Deep breathing, ACBT and supported cough; early sitting and walking.
• Early on, a firm pad may be used over the chest wall to limit paradoxical movement; support the area when coughing.
• Shoulder exercises on the operated side from day 1 (muscles cut over the scapula).
• Posture correction in front of a mirror and trunk exercises to prevent scoliosis and a dropped shoulder.
• Later: exercise training, thoracic mobility, return to work.

13Precautions and infection control

14Education

• Take every dose of TB medicine for the full course, even when you feel better.
• Cover your mouth when coughing; keep windows open; dispose of sputum safely.
• Eat enough protein and calories; stop smoking and alcohol.
• Continue daily breathing exercises, airway clearance and walking after cure.
• Report return of fever, weight loss or blood in sputum.

15Prognosis

Drug-sensitive TB is curable with full treatment. Many survivors are left with some lung damage, which causes breathlessness and infections for life; pulmonary rehabilitation improves exercise capacity and quality of life.

16Exam corner

• W18 Q4(b), 5 + 5 + 5 marks52-year-old nurse, thoracoplasty 2 days ago for tuberculosis. Functional diagnosis; short- and long-term management.
• S22 Q4(b), 15 marksThe worked example in section 10.
• S24 Q4(a), 15 marks25-year-old student with a right destroyed lung after TB; crackles over the right upper chest; pain on deep breathing and coughing on the right; cannot run or play sport; HR 105/min, RR 28/min; FEV1 60% and FVC 56% predicted. Functional diagnosis and management.
• RelatedPost-TB bronchiectasis cases S19, S20, S21 and W24 (see the bronchiectasis page). Pneumonectomy for a destroyed lung (S26) and lobectomy after old TB (S25): see the lung surgery page.

Technique cards for this topic: airway clearance, ACBT and autogenic drainage, exercise testing, pulmonary rehabilitation.

Keywords to underline

infection control N95 NTEP post-TB lung disease destroyed lung fibrosis, tracheal shift airway clearance pulmonary rehabilitation thoracoplasty: posture and shoulder