[Expert consensus on the diagnosis and treatment of severe pulmonary tuberculosis].

Patients with pulmonary tuberculosis (PTB) progressing severe conditions have a poor prognosis and high mortality. To enhance the scientificity and standardization of the diagnosis and treatment of severe PTB, the Chinese Society of Tuberculosis of Chinese Medical Association organized domestic experts to formulate the "Expert Consensus on the Diagnosis and Treatment of Severe Pulmonary Tuberculosis". The consensus presents 19 recommendation statements across the following 12 aspects, aiming to provide a decision-making basis for improving the management of severe PTB.The recommendations are listed below:Recommendation 1: Severe pulmonary tuberculosis refers to PTB accompanied with severe pulmonary parenchymal damage or functional impairment with severe hypoxemia, with or without serious complications (2, C).Recommendation 2: Based on clinical characteristics, severe PTB can be classified into the following three types, with diagnostic criteria as follows:Type Ⅰ: Severe Pulmonary Parenchymal Damage Type: Both of the following criteria must be met: (1) PTB lesion extent involving ≤2 lung fields accompanied by caseous consolidation, cavitary necrosis, etc., OR lesion extent involving ≥3 lung fields, OR tracheal stenosis; (2) Oxygenation index (PaO2/FiO2)≤300 mmHg or arterial partial pressure of oxygen (PaO2)≤60 mmHg (1 mmHg=0.133 kPa).Type Ⅱ: Severe Complication Type: PTB with any one of the following severe complications, concurrently with PaO2/FiO2≤300 mmHg or PaO2≤60 mmHg: (1) Central airway stenosis; (2) Massive hemoptysis; (3) Tension pneumothorax; (4) Respiratory rate ≥30 breaths/min; (5) Heart failure; (6) Liver failure; (7) Renal failure; (8) Impaired consciousness and/or disorientation.Type Ⅲ: Critical Illness Type: PTB with shock or multiple organ failure requiring admission to the ICU for respiratory, circulatory, or other organ support (2, C).Recommendation 3: Diabetes mellitus, advanced age, malnutrition, immunosuppressed status, renal insufficiency, and multidrug-resistant tuberculosis (MDR-TB) are high-risk factors for severe PTB (1, B).Recommendation 4: The anti-tuberculosis treatment for severe PTB follows the principles of early, combined, regular, adequate, full-course, and individualized therapy. Based on standardized first-line regimens, high-efficacy, low-toxicity second-line anti-TB drugs may be selected based on the patient's specific condition (2, B).Recommendation 5: For patients with severe PTB, it is recommended to initiate anti-TB treatment as early as possible when the clinical condition permits. Drug selection should be appropriate based on the patient's organ function (2, B).Recommendation 6: For severe PTB patients complicated with gastrointestinal dysfunction, it is recommended to initiate intravenous administration of anti-TB drugs early to rapidly achieve and maintain therapeutic blood drug levels, transitioning to oral administration gradually once the condition stabilizes (2, C).Recommendation 7: Interactions exist between anti-TB drugs and various antifungal agents. It is recommended to select anti-TB and antifungal drugs based on the patient's condition and the type of drug interactions (1, B).Recommendation 8: For severe PTB patients with HIV infection, antiretroviral therapy (ART) should be initiated as soon as possible, preferably within 2 weeks of initiating anti-TB treatment. The selection of anti-TB and antiretroviral drugs should be based on the patient's condition and drug interactions (1, B).Recommendation 9: For severe PTB patients with acute respiratory distress syndrome (ARDS), corticosteroid adjuvant therapy may be administered, under the premise of effective anti-tuberculosis treatment(1, B).Recommendation 10: Nutritional risk screening is recommended for patients with severe PTB. Early enteral nutrition for hemodynamically stable patients can improve prognosis and reduce mortality (1, B).Recommendation 11: For severe PTB patients with massive hemoptysis, rapid relief of airway obstruction and ensuring oxygen delivery are mandatory. After stabilization, computed tomography angiography (CTA) of the chest should be performed. Vascular interventional therapy or surgical intervention should be considered if necessary (1, C).Recommendation 12: For severe PTB patients with circulatory dysfunction, non-invasive/invasive hemodynamic monitoring should be performed, accompanied by fluid resuscitation and vasoactive drug support therapy (1, B).Recommendation 13: For patients with septic shock, early initiation of cytokine adsorption therapy is suggested (2, C).Recommendation 14: For severe PTB patients with severe renal failure, renal replacement therapy should be considered (2, B).Recommendation 15: For severe PTB patients with hepatic injury, close monitoring is essential. Drugs with a high incidence of hepatotoxicity should be discontinued, and comprehensive treatment including hepatoprotective therapy and supportive care should be provided (2, B).Recommendation 16: For severe PTB patients with respiratory failure, personalized respiratory support modalities is recommended (1, B).Recommendation 17: Attention must be paid to infection control management related to high-risk respiratory therapy operations for severe PTB patients (2, C).Recommendation 18: Extracorporeal membrane oxygenation (ECMO) therapy can be considered for severe PTB patients with ARDS (2, C).Recommendation 19: Early rehabilitation therapy is recommended for severe PTB patients. Safety assessment should be conducted prior to rehabilitation, with real-time monitoring of vital signs and rehabilitation should be terminated promptly if necessary(2, B).