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Written by NurseRatchet




Pulmonary Tuberculosis Protocol

Tuberculosis (TB) can attack many different parts of the body, but in developed countries, it is usually found in the lungs. For that reason only the lung, or pulmonary, form of the disease will be discussed here.

As always, this information is provided for educational purposes only. See your health care provider for your personal medical needs.

General Information

Tuberculosis or TB was very common in this country before antibiotics were developed. At that time, it was called Consumption and was a major cause of death. It is still a common cause of death in developing countries. It is caused by the tiny, slow growing bacteria Mycobacterium tuberculosis. The bacteria lodges in the lungs and can become active immediately or wait months or years to emerge as an active infection. It is terminal if left untreated.

TB is one of the few diseases that are spread in the air from the sick person coughing or breathing. The bacteria ride in the air as tiny droplets that may stay airborne for hours. It is spread by inhaling these droplets. Because of this, patients with known TB must have special isolation precautions.

Active infections of TB can come from a new exposure to the bacteria or from reactivation of the disease from an old exposure. People with weak immune systems are more likely to have active TB. This would include the elderly, children, people with HIV/AIDS, people with diabetes, or anyone who has been “worn down” from lack of sleep or lack of proper nutrition.

TB will be difficult, if not impossible, to treat in TEOTWAWKI situation. The best course is prevention. Encourage everyone in your party to be screened annually for TB. The test is cheap and easy. If someone in your group has been exposed, REQUIRE them to go through the full course of treatment, which can take up to 9 months. Put refugees through a period of quarantine to make sure you’re not infecting the group.


Diagnosis of TB is next to impossible without labs and x-rays. It shares symptoms with many other respiratory infections. Since TB is not extremely common in this country at this time, suspect other problems before you suspect TB.

1) Presence of signs and symptoms.
2) Treatment for other respiratory infections has not cleared the problem.
3) The following would increase your suspicion of TB:
___a) History of exposure to someone with active TB.
___b) History of previous active TB.
___c) History of a positive TB test (also called a PPD test or a Mantoux test) in the past.
___d) History of travel to a country where TB is common (most third world nations).
___e) History of working/living in a high-risk area: hospital, nursing home, prison, group home, drug treatment center, refugee camp, etc.

Signs and Symptoms

Pulmonary TB is often so nearly asymptomatic (showing no signs or symptoms) that the patient may deny all symptoms except "not feeling well".

Cough that does not go away is the most common symptom. The patient often ignores it and attributes it to smoking or a cold. The sputum (the junk that’s coughed up) is yellow or green. At first, this is just a small amount first thing in the morning, but becomes more productive as the disease progresses.
Dyspnea (shortness of breath) may result from damage to the lung by the bacteria.
Hemoptysis (coughing up blood) usually does not occur until the later stage of TB
Unexplained weight loss
Night sweats from a fever that spikes up at night and is down during the day.

The drugs used to treat TB are expensive, specialized, and very hard to get. They also must be given daily for a period of 6 to 9 months. Chances are they’ll only be available in the unlikely event that your retreat is a pharmacy. Use supportive, non-drug treatment until advanced medical help is available. If not available, use of supportive and eventually palliative care will be your most likely option.

Treatment can be complicated by the presence of strains (particular “families” of the bacteria) that have grown resistant to the antibiotics used to treat TB.

If not drug resistant:

Isoniazid 300mg one by mouth once a day for 9 months
[and] rifampin 600mg one by mouth once a day for 9 months
[WITH] pyridoxine (Vitamin B6) 25mg by mouth once a day for 9 months


Rifamate (a combination drug with Isoniazid 150mg and rifampin 300mg) two by mouth once a day for 9 months. Take on an empty stomach.
[WITH] pyridoxine (Vitamin B6) 25mg one by mouth once a day for 9 months.

For known drug resistant strains of TB:

Isoniazid (INH) 300mg one by mouth once a day for 6 months
[and] Rifampin 600mg one by mouth once a day for 6 months
[and] ethambutol 15mg/kg one by mouth once a day for 2 months
[and] pyrazinamide 25mg/kg one by mouth once a day for 2 months (max 2.5g/d)
[WITH] pyridoxine (Vitamin B6) 25mg by mouth once a day for 6 months.

Supportive Care

1)Respiratory isolation as listed below.
2)Supplemental oxygen (if available) to treat shortness of breath.
3)Keep head of bed raised to treat shortness of breath.
4)Maintain nutritional intake to support the body's fight with the infection.
5)Acetaminophen/Tylenol, ibuprofen/Advil, or aspirin for fever control.
6)Encourage rest. The body needs energy to fight the infection.

Special Precautions
Patients with active TB require respiratory isolation in addition to standard infection control precautions to prevent spread of the disease.

1) Patient remains in a room alone or only with others with active TB.
2) Patient is taught to cover mouth and nose at all times when coughing or sneezing.
3) Room should have negative pressure (pulls air FROM the rest of the building, exhausts it outside where others won’t be breathing) if available, or a separate building or shelter,
4) Caregivers wear properly fitted HEPA masks when entering patient room.
5) Caregivers use good hand washing after care.
6) Patient should wear a HEPA mask WITH NO EXHALATION VALVE when in common areas.

If antibiotic treatment is available, the patient can usually be taken off respiratory isolation after 2 weeks of treatment.


ePocrates qID database
ePocrates qRx database
The Merck Manual
Infection Prevention and Safe Practice; Schaffer, Garzon, Heroux, and Korniewicz. 1996, Mosby

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