The PNEUMOLOGY  activity is performed under the scientific and professional coordination of Prof. Univ. Dr. VOICU TUDORACHE, and the consultations are offered by Dr. FILIP ANDREEA SUSANA, Dr. GORON MONICA, Dr. JAGER ANCA GEORGIANA and Dr. SOMEȘAN IOAN ALEXANDRU

BRONCHIAL ASTHMA

What is bronchial asthma?

It's a chronic inflammatory disease, that affects the bronchus. Because a chronic inflammation from the bronchus, seizures produce: bronchus spasms, that get narrow suddenly and the patient feels like he is choking, has difficulties in expiring more than in inhaling, noises (whistle) are heard when breathing.

What is asthma?

Most of the times, asthma is a respiratory allergy, of predisposed people (with atopic terrain). There is an hereditary transmission of this predisposition, so in the same family there could be more patients with asthma or other allergy forms (allergic rhinitis, eczema, aspirin allergy).

The disease starts manifesting in one moment, with the occasion of a virosis, either with an exposure to aerosolized allergens (pollen for example), Inflamed bronchus react exaggerated toward inhaled particles, that provoke a sudden narrowing of the bronchus: an asthma crisis appears, easily recognized by the doctors that see the patient. Still, there is a possibility that the first seizures won't be observed and after, related by the patient as "frequent colds", because the patient accuses a clogged nose and cough, but never fever.

Once started, the disease has a chronic evolution. It has a permanent presence in the bronchus, but it's experienced, by the patient, only during seizures. Between the seizures, the patient can feel good and can think that he is healthy.

How does asthma manifest?

By suffocation crisis together with chest whistle, cough that can eliminate white jelly sputum. Sometimes, the patients have the sensation that "the chest is tightening" or that "they breath through a gauze". The disease has its debut, usually, in young persons or even children. There are also patients where the disease has its debut after the age of 60.

Between the seizures, the patient might fell perfectly healthy, or might have difficulty in breathing in effort.

The disease might take different severity degrees. When it's facile, it could manifest through rare seizures, of small intensity that pass without treatment. If the disease is severe, the crisis might appear more often, even daily, or during the night, awakening the patient. In this stage, the patient does not feel good between the seizures either, accusing small effort fatigue, permanent whistle in the chest, cough. A patient that usually has rare crisis might pass through a symptom aggravation period, often triggered by a respiratory virosis or exposure to an allergen (for example- poplar blooming). Then, he makes an exacerbation of the disease, that takes him to a doctor.

Bronchus inflammation is permanently present in asthmatics. If it is strong, the seizures are more frequent and severe, leading to chronic manifestations.

How do you diagnose asthma?

The diagnose is established based on the clinical manifestations, suggestive history and spirometry (respiratory capacity measuring).

The diagnosis is easy in young patients, non smokers, that accuse typical suffocation crisis, joined by chest whistle and, eventually, cough with white clammy expectoration. Things are not as easy for elder patients, especially if they are smokers, that accuse more fatigue in effort, or cough crisis, more than suffocation crisis. In seizure (sometimes even between seizures), the doctor can hear, with the stethoscope, sibilant rales (whistles) in the patient's lungs.

Spirometry is essential for the diagnosis, for establishing the disease's severity, and for observing its evolution in time. The patient is asked to blow, with a maximum force, in an apparatus that measures respiratory parameters. Asthmatics can have normal spirometry between seizures, or an obstructive syndrome might be observed ( a parameter called VEMS is reduced). Very suggestive for asthma is the increase or normalization of VEMS after the inhalation of a bronchodilator.

What to do?

Hygiene measures.

Asthma, being an allergic disease, most of the times, the patient must avoid, as much as possible, the inhalation of particles that trigger its seizures. Because, most of the times, it's impossible to identify what triggers the seizure (or because the patient reacts exaggerated to many particles), some general measures are recommended:

-the sleeping room of the asthma patient must be clean and austerely: no dust or things that hold dust (carpets, libraries, curtains), dust aspiration (by somebody else than the patient) including of the walls. The pillow, coverlet and mattress must be from synthetic materials (no wool or feathers).

-apartment plants must be avoided, especially those with flowers, but also those which maintain must on the soil or pot. Parma Viola seem to be one of the most allergenic plants;

-aquarium fish can do an indirect harm, through the fleas that he eats, that could be inhaled when given to the fish;

-animal hair (cats, dogs) can aggravate the asthma's symptoms.

Asthma elementary treatment.

Asthma, being a chronic disease, must be treated in permanence, not only during seizures. A correct treatment prevents the apparition of other seizures.

The treatment must be adapted depending on the severity degree of the disease, telling the number or the medicines and their doses.

Asthma is not a curable disease, but it's easy to treat it, the abject being that the patient might have a normal life, with the price of a treatment administration.

Medicamentary treatment principles:

Any asthmatic must know that there are useful medicines for chronic treatment and other medicines that are useful only during seizure (saving treatment).

The most simple therapy in asthma is inhalation therapy (with sprays). It must be seen as a beginning treatment, not as a treatment for the last stage of the disease. The sprays contain small quantities of medicine that go only to the bronchus, having no general effect (they are in fact a local treatment). So, sprays are adequate for long term treatment, without any adverse effect over the entire body. Sprays don't give dependency: they can be necessary the entire life, because the disease they treat, the asthma, is a chronic disease. Correct use of sprays:

-elementary treatment: corticosteroids spray (in an adapted dose for the severity degree), salmeterol spray, montelukast, or their combinations.

-saving treatment: salbutamol or astrovent sprays (there is also a solution for aerosol or some injectable solutions).

The most simple therapy:

-a costisone spray, used daily n the prescribed dose,

-a salbutamol spray, used if necessary (suffocation seizure, cough, chest constriction sensation or any other respiratory symptom). If the need is daily, and exceeds 6-8 pufs, it means that the disease is not well controlled and the elementary treatment must be amplified.

The fear for cortisone: most of the times, the asthmatics are afraid, with good reason, of cortisone used on a long period of time. It's true that bones, metabolic, gastric, and skin adverse effects appear in case of cortisone in form of injections and pills. But not for spray, that has a small dose of cortisone, and doesn't have an effect over the entire body.

Exacerbated asthma treatment.

The best prevention of crisis and exacerbation is a correct elementary treatment. Even so, asthmatics can have bad periods, sometimes in the same season, when the disease aggravates. A medical consult is necessary and a spirometry, to appreciate the severity of the exacerbation. Sometimes, the situation imposes hospitalization. No mather how well they felt, asthmatics could benefit of a short treatment (7-10 days) with prednisone (cortisone pills), that has no negative impact on a long term. There can also be useful: increasing the cortisone spray dose, increasing the dose of bronchodilator spray or associating more types of bronchodilators.

Chronic obstructive bronchopneumopathy (COPD)

What is COPD?

COPD is a chronic respiratory disease that affects both the bronchi (chronic bronchitis) and the lungs (emphysema) and manifests through a progressive and irreversible narrowing of the bronchi, that comes along with a progressive decrease of the respiratory capacity..

What provokes COPD?
Smoking is the main cause of COPD! In the majority of cases, COPD appears in smokers, after the age of 40. Not all smokers get COPD, but it has been observed that a ratio of 10-15% of smokers, that probably have an unknown predisposition, react exaggerated to cigarette smoke. The result is a chronic inflammation of the bronchi and the lungs that leads to a progressive narrowing of the bronchi and the destruction of the pulmonary alveoli (emphysema).

Aside from smoking, COPD can also be favored by atmospheric pollution, passive smoking (for non-smokers that inhale other people's cigarette smoke), or by heating systems that work with coal.

How does COPD manifest?
Smokers consider that it is normal for them to cough, that is the reason why coughing, although present in many patients with COPD, does not alarm them. With the bronchi narrowing and the respiratory capacity decreasing, the patient start to feel a lack of air (dyspnea) in efforts that were easily done in the past. Often, when the effort fatigue is annoying enough to address a doctor, the respiratory capacity has already dropped to half. Because of this effort tolerance decrease, suffocation seizures might appear (mistaken with asthma) and frequent infectious respiratory episodes, especially in the winter, when the patient coughs more and expectorates purulent. Often, COPD is found with the occasion of such an infectious episode.

In time, after the disease progresses, dyspnea is felt in smaller and smaller efforts, until the patient has to stay at home all the time. The immobility that the disease induces determines depression and nervosity. In time, heart complications may appear: swollen legs, livid lips. Without a treatment, COPD determines the premature and severe reducing of the respiratory capacity, that leads to invalidity and premature death.

It has been estimated that in the next 20 years, mortality by COPD will increase so much that it will beat cardiovascular diseases..

How do you diagnose COPD?
The disease must be suspected in all smokers that accuse dyspnea in moderate efforts. For a correct diagnosis, and also for the evaluation of the severity and evolution in time, spirometry is necessary (measuring the respiratory capacity). The patient is asked to breath in the apparatus, as hard as he can, Spirometry shows a broncho obstructive syndrome, with a reduced parameter called VEMS. The severity of the disease is appreciated depending on the decrease of VEMS. Most of the times, patients arrive to the doctor when VEMS in at about 50% of normal.

COPD is an irreversible disease; usually therapeutic intervention does not manage to bring the respiratory capacity to normal, but only to stop the decrease; so, an early diagnosis is very important.

How is COPD treated?
Treatment objectives: once established, this disease does not disappear; the treatment only stops the decrease of VEMS and improves the effort dyspnea that the patient feels.

Although it seems small, these realizations are major for the patient, if after the treatment he can go out of the house and help himself.

Quit smoking. The first treatment measure is to quit smoking, the main factor of COPD. The patient must understand that the disease is produced by smoking, and to stop this habit is to bring direct benefits. Bronchodilators administrated with regularity, with a single medicine or more (salbutamol spray, atrovent spray, theophylline pills). The most useful are the bronchodilators with prolonged action (salmeterol, tiotropium). For moderate and severe stage, the association with a cortisone spray is useful. This medicine can help the patient with the symptoms, by making the acute episodes rare and by slowing down the decline of the respiratory capacity. It is not proven that other medicines like cough medicine, and antibiotics have any effectiveness.

Anti-flu vaccine, in autumn, it's proven to be affective in prevention of acute viral episodes.

Exacerbation treatment. We consider COPD exacerbation a period when the symptoms aggravate or new symptoms appear: cough intensification, productive cough with purulent expectoration, accentuated dyspnea so the patient gets tired in the smallest of efforts. The episode could be triggered by a virosis or other unidentified factors. The doctor must appreciate if the exacerbation can be treated at home or hospitalization is necessary. Sometimes the exacerbation could be so severe that hospitalization in the Intensive Care area is necessary, for some patients mechanic ventilation is necessary to keep the alive. The exacerbation's treatment usually is the increase of bronchodilator's dosage and the introduction of an antibiotic and/or cortisone orally administrated. In the hospital, the patient benefit from oxygen and treatment for the cardiac complications.

What else do you need to know!
Smoking might cause an entire series of respiratory diseases, but also of other organs. The association between COPD and lung cancer is not rare; the disease's combination make the prognosis worst, because the patient can not be operated for cancer because they have a low respiratory capacity and would's resist to the surgery. Smoking also provokes larynx and stomach cancer, and favors many other types of cancer. Smoking provokes gastric ulcer and the narrowing of the arteries from the entire body, but the most severe are the affections of the coronary artery (that fed the heart) provoking heart failure, and the leg arteries, leading to arteritis (decreased irrigation may lead to tissue death- gangrene- that could impose the leg amputation). Smoking makes the skin look older, accentuates wrinkles and thickens the voice.

Lung cancer

Lung cancer is one of the most severe consequences of smoking. 

In one bronchus or inside the lung a malign tumor is developing, that evolves for a long time without symptoms. In its development, it can invade neighbour anatomic structures (heart, vessels, ribs) or could send cells in other organs (brain, liver, bones) producing metastases.

What provokes lung cancer?

Main risk factor: smoking (although there are not many smokers that develop lung cancer, it is known that 85% of patients with lung cancer are smokers). Cigarette smoke is a killing composite of cancer causing substances that could provoke, earlier or later, cancer. That is why, the risk for smokers is cumulative, if they smoke for a long time the risk for cancer increases. The other way around, the ones who abandon smoking have a smaller and smaller risk to develop cancer, but they become non-smokers only after 10 years.

How does lung cancer manifest?

Unfortunately, many times, lung cancer starts to manifest only after it has evolved for a long time in silence, making the diagnosis to be found only in advanced stages. Cough (or the change in the cough's character) is a symptom,often neglected by smokers, that consider cough "normal". Expectoration with blood striae or even haemoptysis (blood expectoration) are often so alarming that the patient presents to the doctor the next day. The patients may also accuse persistent thorax pain, weigh loss, lack of appetite, raucity with recent apparition and that does not go away, lack of air. None of the symptoms is typical. Many times the symptoms may lack entirely and the problem is discovered with the occasion of a rutin control  .

How is it diagnosed?

Lung radiography could show the presence of a tumor in the form of spots with different dimensions in one of the lungs. Normal radiography does not exclude the presence of a small tumor, hidden behind the heart, for example. Sometimes a pleural effusion might appear (fluid accumulation in the thorax), that could be a complication of lung cancer.

Bronchoscopy is an essential investigation for the diagnosis. It could highlight the tumor that developed inside the bronchus, it brings information about its location and about the possibility of surgery.

Through bronchoscopy, a tumor biopsy is possible, meaning a fragment of about 1 mm3 from the modified zone could be pinched, that it's sent to the pathology anatomy laboratory. Here, it can be said if the harvested tissue is cancerous (malign) and from what type of cells is it made off. Bronchial biopsy (like any other biopsy) does not provoke cancer, it only highlights the existing cancer. Even more, the biopsy take-off does not determine the cancer to "spread'.

CT shows the tumor's location even better, allows to appreciate its extension toward the neighbour tissues and the presence of metastases.

CT can not replace the bronchoscopy because it does not allow biopsy and the highlight of cancer cells.

Pleural puncture is compulsory when the lung tumor comes along with pleurisy. The liquid might often be hemorrhagic. The analysis of cells from the liquid could highlight cancer cells.

Other investigations might be useful: abdominal ecography could highlight liver metastases, bone scintigraphy the bones metastases etc.

Cancer diagnosis is secure when cancer cells are found in bronchial biopsy or in aspirated secretions during the bronchoscopy or in the pleural liquid.

Tumor staging.

After it is established that it's lung cancer, the doctor must appreciate, based on the investigations, what is the stage of the disease. The treatment and the prognosis depend of this. The stage is appreciated based on the position of the tumor (T), the presence of ganglia (N) and of the metastases (M). For example, a small tumor of 3cm, that only affects a small bronchus and it's accompanied by a small lung ganglion on the same side with the tumor, without metastases, is stage II, benefits from an effective treatment and  good prognosis. A tumor larger than 10cm, that affects a large bronchus or even the trachea, is accompanied by a palpable ganglion at the base of the neck and of liver metastases is a stage IV, benefits of few therapy options and has a bad prognosis.

Treatment.

Unfortunately, lung cancer remains a unconquered redoubt of modern medicine. Frequent tracing of the disease in advanced stages and the modest answer of anti-cancer drugs makes the healing to be expected very rare.

The best treatment is surgery (with complete exclusion of the cancer tissue, often an entire lung), followed by cytostatic chemotherapy (that addresses to the cells that might have "walked away" but have not formed metastases yet).

For every case operation possibilities must be evaluated. For this, the patient must have an acceptable respiratory capacity (so after the surgery he has no problems in breathing), a healthy heart, an acceptable nutrition, but especially the tumor must be in a stage that allows surgery (from I to III). Patients that can not be operated, from various reasons, are directed to the oncology department where it is appreciated if they benefit or not from cytostatic treatment. More oncology services do not accept (and with good reason) the initiation of such an aggressive treatment if there is no confirmation of cancer, through biopsy or cytology. Cytostatic treatment is administrated in 2-3 days cures, for 3-4 weeks intervals. Usually, combinations of 2 medicines in 6 cures are used. Radiotherapy can be associated, that is made in sessions of 10-15 consecutive days, directed towards a lung or the place of a metastasis (brain, for example).

Citostatics often have serious adverse reactions: vomit, bad condition, hair loss, anemia. They can be beaten with drugs, but especially with the patient's belief that the disease that he is fighting is more serious than the adverse reactions. For this, the patient must know the disease he is fighting with. That is why, the insistence of the families to hide the truth from the patient are not justified.

Patients in advanced stages, with a bad general condition, that do not feed well, don't have any benefits from chemotherapy. In their cases, the balance between benefits and adverse reactions inclines toward the last. They benefit from palliative and symptom therapy: pain therapy, cough, dyspnea, psychologic counseling.

Evolution.

Lung cancer does not heal by itself. Untreated, it evolves very fast, most of the times, with the accentuation of the symptoms, weigh loss, complete loss of appetite, bad general condition, that goes toward death in intervals that vary from a few months to a year, from the date of the diagnosis. There are also cases that evolve slower, but there are also others where a complication (like a massive haemoptysis) can lead to sudden death. The combined surgical and oncology treatment improves surviving with a few years. If the treatment is done in an early stage, the chances to survive increase.

In short...
Early discovery of lung cancer can radically change the patient's chances. That is why presenting to a doctor must not be delayed, if respiratory symptoms appear.

Smoking is "the executioner" that kills through cancer! If other diseases caused by smoking give the patient a chance to "repent", lung cancer is a one way road; that is why the best prophilaxy of lung cancer is abandoning smoking early.

Tuberculosis

What is tuberculosis?

It is a malady provoked by a microbe, Koch bacillus, that mainly affects the lungs, but can also affect other organs (ganglions, bones, meninges, kidney etc).

History of tuberculosis
Tuberculosis is one of the oldest known disease, it accompanied humanity from the ancient times ( holes were found in the lungs of Egyptian mummies). Phthisis was always a severe disease that lead to death, most of the times. The fight with the disease was taken with rest, good food, mountain vacations, and later with surgical techniques for lung collapse. The discovery of tuberculosis drugs changed the evolution of tuberculosis radically, the disease became a simple curable infectious disease. Unfortunately, the disgust and fear aura towards the ex redoubtable disease is kept in out days too.

Robert Koch discovered the bacillus that wears his name, on 24 of March 1882, so every year on the 24 of March it's the International tuberculosis day, and actions of popularization of knowledge about the disease are organized.

Tuberculosis in Romania
Tuberculosis is met in our country more often than in other European countries: annually there are 130 cases in 100.000 inhabitants, meaning aprox. 30.000 patients in the entire country (European ration: 30 in 100.000 inhabitants. Young men are frequently affected. In Romania, there is a chain of sanitary units that treat tuberculosis, so anybody, depending on the domicile, has access to a pneumo-phthisiology hospital and to a profile clinic, that can assure the diagnosis and the free treatment until healing. In every county there is at least one hospital and 5-7 clinics of pneumo-phthisiology  .

How is  tuberculosis transmitted?
The bacillus source is the pulmonary tuberculosis patient, that has not started treatment. He coughs and throws live bacilli in the atmosphere, that can be inhaled by the ones next to him. The most affected are the family members, especially children, that are exposed to the infected air for a long time. Work colleagues or close friends may be affected. The transmission way is by air (not by food, clothes or dirty hands). The ones from nearby inhale the bacilli and get infected, without getting sick. In their lungs, the bacilli are surrounded by a defence "barrier" that stop them from developing. The bacilli infection does not mean that you get sick with tuberculosis. It is possible that after a period of time (months or even years) the defence "barrier" to disappear, when the organism is weak because of different situations: insufficient food, fatigue, stress, alcoholism, diets, other diseases like diabetes, treatments that decrease immunity (cortisone) or HIV infection. Then, the bacillus awakens, starts to proliferate and produces tuberculosis.

So the circle is continued, the new patient being the source of infection for other persons.

Tuberculosis is like a bomb with "delayed effect", the interval between the infection and getting sick being impossible to mention.

Children may get sick directly, without such an interval, through contamination from their sick parents or grandparents (they make primary tuberculosis).

How does tuberculosis manifest?

The most characteristic symptom is cough, that is persistent (over 3 weeks), it is progressively accentuated and comes with expectoration. The patients might also accuse fever, lack of appetite, weakness, blood expectoration (hamophthisis). Most of the times, the symptoms appear insidiously, and many patients delay heir visit to the doctor, hoping that they will pass. It must be known that in this period of symptoms, before presenting to the doctor, the patients are highly contagious. the later they go to the doctor the more people will they infect.

How is the diagnosis established?
Any person that has suggestive symptoms of tuberculosis (especially cough) must present to the doctor. Usually, it is recommended a pulmonary X-ray that could highlight modifications that are given by tuberculosis. The patient must be immediately hospitalized , to establish the diagnosis and start the treatment. 

The diagnosis is established only based on a radiography!

For tuberculosis diagnosis the highlight of the Koch bacillus ,in sputum,is essential. Usually, the patients expectorate easily and give sputum for analysis. For those who do not expectorate, bronchoscopy for secretion aspiration, from the bronchi, might be necessary. From the sputum, a microscopic exam, with fast result, is made, and a culture that could last for 2 months.

Sputum exams are essential for the diagnosis, for following the evolution under treatment, and for appreciating the healing.

Tuberculosis treatment 
It is recommended that the treatment of tuberculosis starts in the hospital. So, certain adverse effects of the treatment may be identified and corrected, the patient has time to cure and learn how to take his treatment, but especially, he is isolated while he is still contagious. The patient is not contagious after 2-3 weeks of treatment, but considering that usually in this moment he still expectorates sputum with bacilli, the patients are hospitalized for 1 month. 

The treatment has two stages: attack and continuance. In the attack stage, the patient receives, usually, in the hospital, 4 antibiotics simultaneously (Isoniazid, Rifampin, Ethambutol, Pyrazinamide), every day (or with a break on Sunday- 6/7). The attack stage last for 2 months, and at its end there should not be any bacilli in the sputum. The continuance stage lasts for another 4-6 months, the patient receiving 2 kind of drugs (Izoniazid and Rifampin) 3 times a week (3/7).

The patient is discharged after 1- months of treatment and must address to the local pneumo-phthisiology clinic that will give him the free treatment, periodic controls and will declare him healthy at the end of the treatment.

It is ideal that the treatment is administrated under the direct observation of the medical staff (DOT-directly observed treatment). The patient must swallow the drugs in front of the nurse that gives him the daily dosage. DOT is mandatory in the hospital and it is desired in the ambulatory. Because many clinics are far from the domicile places of the patients, a good relation with the family doctor near the patient is desired, he can organize the administration under direct observation of the treatment in the village where the patient lives.

Evolution of tuberculosis
Left untreated, tuberculosis does not heal! The thing that must not be forgotten is that before the antibiotics era, phthisis was a synonym for death! The holes from the lungs extend and grow bigger, the patient gets weaker and weaker, and after all of this he dies of respiratory failure or massive hemophthisis.

We see cases, even in our days, where the patients suffer at home for 6-8 months before they are being brought at the hospital with the ambulance.

Treated, tuberculosis is one of the most curable infectious diseases. The treatment is very effective in killing the microbes and healing the lungs. The faster you start the treatment, the better the disease disappears, with fewer sequela. A patient that is healed of tuberculosis becomes a normal person, can be integrated in society and can continue his life that was interrupted by the disease.

Problems of tuberculosis's treatment
Koch bacillus is very different to other microbes, so the treatment has some particularities. To obtain healing, a complex treatment is mandatory (with 4 types of medicines), for a long period of time (at least 6 months). Not respecting these indications leads to a failure of the treatment and a tuberculosis relapse.

If the treatment  scheme is not respected and the patient refuses to take one medicine (from different reasons like bad taste of one pill, or an unresolved adverse reaction), the bacillus develops a resistance to the other medicines and becomes harder (or impossible) to kill.

If the treatment is interrupted before 6 months, the lesions do not sterilize, there are enough bacilli left n them to lead to a relapse after a period of tranquility. 

So, for a successful battle against tuberculosis, the patient's cooperation and the keeping of the treatment scheme are essential. These things look, pretty often, strange to the patients that feel better after the first weeks of treatment, and they do not understand why they need to take so many pills for such a long period of time.

 Social and psychological implications
Tuberculosis if often referred to as a "poverty" disease and that is why many patients do not want to admit their disease. They are afraid that they will be avoided by friends and fired. Unfortunately, their denial goes to the point that they refuse medical care, hospitalization, treatment, and this transforms them in true "biologic bombs" for those who surround them.

Tuberculosis is not just a problem of the patient, but is a collective problem, benig highly contagious. So, a person who got sick, but is doing everything he can to get treated and healed must be seen with compassion and encouraged, and one who knows that he is sick but refuses to get treated must be encouraged to ask for medical care.

Tuberculosis does not have to be seen with disgust, but like a serious problem, with known causes, but with easy solutions, that must be resolved.

In short...
Tuberculosis is the most curable infectious disease.

The transmission way s through the air, from a sick person.

The treatment lasts for at least 6 months and implies a scheme of different antibiotics.

The treatment is free.

Anyone has access to tuberculosis treatment.

An ex tuberculosis patient, once healed, is a normal person.

Anyone can get tuberculosis.

Left untreated, tuberculosis is deadly!

 Correct use of sprays

The classical "spray" (metered dose inhaler-MDI) releases, with every press, a dose of the medicine. To obtain the best result, its administration must be correct and the active substance must get to the lungs. Incorrect use will lead to the wrong idea that the spray in ineffectual.

Here are the steps of a correct administration of a puffer: 
-clear the cap