Pulmonary Rehabilitation in Posttubercular Sequelae – An Ignored Entity

To the Editor, Although it is still not widely utilized, pulmonary rehabilitation (PR) is an effective treatment for patients with chronic lung disease. PR is defined as "a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease, and to promote the long-term adherence to health-enhancing behaviors.[1] There are no Indian guidelines for PR. Recently, clinical practice guidelines for PR were published by the American Thoracic Society.[2] These guidelines focused on PR in chronic obstructive pulmonary disease patients, both stable patients and in the post exacerbation, interstitial lung disease patients, and patients with pulmonary hypertension (PH). However, PR in posttuberculosis lung disease (PTLD) was missing in these guidelines. The reasons could include uncommon diagnoses and lack of literature evidence. However, for developing countries like India, not having national recommendations for PR in PTLD may also just be because of ignorance. Mycobacterium tuberculosis (TB) affects more than 10 million people annually. In India, a record 24.2 lakh cases were notified in 2022. Up to 50% of TB survivors experience a decline in lung function and impaired quality of life despite microbiological cure.[3] Obstructive as well as restrictive ventilatory defects can occur in these patients due to anatomical and structural changes including cavitation, bronchiectasis, and fibrosis. A minimum case definition of post-TB lung disease has previously been defined as evidence of chronic respiratory abnormality attributable to prior tuberculous infection and it includes various patterns of lung damage usually seen in clinical practice such as TB-associated obstructive lung disease, bronchiectasis, cavitation, parenchymal distortion, fibrotic changes, Aspergillus-related lung disease, chronic pleural disease, and PH.[4] There are few published studies which showed the benefits of PR in patients with a prior history of pulmonary TB and having symptoms of dyspnea attributable to post-TB lung disease. A retrospective analysis was carried out which showed significant improvement in 6-min walk distance, Forced expiratory volume in the first second (FEV1), Forced vital capacity (FVC), and partial pressure of oxygen after completing a 3-week PR program in subjects with the past history of TB and having impaired lung function.[5] A pre–post intervention study conducted in Uganda concluded that PR had a positive effect on the quality of life, exercise capacity, and respiratory outcomes.[6] Patients with post-TB lung disease often do not get access to chronic respiratory disease specialty clinics in India. The capacity of TB providers to assess and manage post-TB lung disease needs to be strengthened to ensure immediate care initiation or referral to chronic respiratory disease clinics. Moreover, post-TB lung disease should be included in TB guidelines to ensure nationwide programmatic care of such patients. The National TB Elimination Program aims to eliminate TB in India by 2025. However, treating post-TB cases also helps to reduce morbidity. To conclude, there is a need of the hour for research and randomized trials on PR in post-TB patients so that recommendations and programmatic guidelines can be formulated.