The Handling of the Poor Risk Patient with Pulmonary Tuberculosis: Antimicrobial Therapy, Cardio-Pulmonary Function and Surgery

¹ The National Jewish Hospital at Denver and the University of Colorado School of Medicine, Denver, Colorado.

At the National Jewish Hospital, we have observed a marked decrease in the percentage of patients with minimal to moderately advanced exudative disease. Those with far advanced fibrocavernous lesions are now our principal concern. These changes in the patient population of our institution together with the more perfectionistic demands as to the results of treatment have necessitated development of the "team concept" of therapy with close coordination between the internist, bacteriologist, physiologist, and surgeon.

As a result of recent advances in chemotherapy, many poor risk patients can now more safely be submitted to definitive major surgical procedures aimed at completing the control of tuberculosis which cannot be achieved (see figure in source pdf) by drugs alone. It is our experience that in the patient with isoniazid-resistant, catalase-negative tubercle bacilli, the risk of serious post-operative spread of disease is minimal or absent.

Thus, careful evaluation of the cardio-respiratory system as to the type and extent of pulmonary insufficiency takes on an even greater importance in selecting patients for major thoracic surgical procedures. In other words, the "tuberculous process" per se is no longer of as much importance as a contraindication for surgery.

Our experience with a wide variety of surgical procedures indicates that broader application of resectional surgery under coverage of isoniazid is now possible and, indeed, definitely indicated to control pulmonary tuberculosis more completely so that a maximum number of patients can be returned earlier to useful lives.