The Guidance Document for Pulmonary Rehabilitation Programme for People affected with Tuberculosis at Rajan Babu Institute of Pulmonary Medicine and Tuberculosis is an initiative by Central TB Division (CTD) and Rajan Babu Institute of Pulmonary Medicine and Tuberculosis (RBIPMT), New Delhi, the Center of Excellence for DR-TB care. The guidelines have been developed as the end product of series of consultations and meetings of the working committee held under the chairperson of Dr Manasi Anand, Director RBIPMT. 
The work on this document was guided and supported by Dr Sanjay Kumar Mattoo, Joint Commissioner and Addl DDG (TB), CTD. We would also like to acknowledge Dr Malik Parmar (NPO, WHO India), Dr Jyoti Jaju (Director Programmes, The Union), Dr Bhavin Vadera (Senior Health Advisor, USAID), Dr Sandeep Chauhan (National Consultant, CTD) and Dr. Manu Mathew (Deputy Director Programmes) for their guidance. We also acknowledge USAID supported The Union led iDEFEAT TB Project for co-ordination and technical assistance.

We express our gratitude to the eminent technical experts involved in the development of the document (alphabetical Order) Dr Anuj Bhatnagar (Head Department of Respiratory Medicine, RBIPMT), Dr Anil Choudhary (Senior Pulmonologist, RBIPMT), Dr Ashwani Khanna (NTEP Advisor, Delhi), Dr B.K Vashishat (STO, Delhi), Dr Bhoomika Varshney (Department of Yoga, RBIPMT), Dr Rakesh Kumar (Physiotherapist, RBIPMT), Dr Rakesh P.S (Senior Technical Advisor, The Union), Dr. Sanjeev Nair (Government Medical College, Thrissur), Dr Shruti Sasastrabudhe (Symbiosis, Pune), Dr Sunalini Saini (Senior Physiotherapist, RBIPMT) Dr Sunita Kujur (CMO, RBIPMT), Dr Vishal Bansal (Vallabhbhai Patel Chest Institute, Delhi), Dr Vaishali  (Dietician, RBIPMT), and Dr Yatin Dholakia (Medical Research, Mumbai). Writing of the document was coordinated by Dr Priyanka Bindroo (Former National Consultant, CTD), Dr Meera Bhatia (Technical Advisor, The Union) and Dr Mayank Mittal (National Consultant, CTD).

Tuberculosis is a major contributor to the pool of individuals who have respiratory insufficiency due to destruction of lung tissue. It has been shown that 65% of patients completing their TB treatment have abnormal lung functions and residual symptoms.

Pulmonary rehabilitation aims to restore the affected individual to an independent, productive and lead a satisfying life and prevent further clinical deterioration to the maximum extent compatible with the stage of the disease. This goal may be accomplished, without materially improving lung function, by helping the patients to become more aware of their disease, more actively involved in their own health care and more independent in performing daily care activities, attempting to reverse the disability from disease.

Pulmonary rehabilitation is 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 behaviour change. It is designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours. Pulmonary rehabilitation provided to individuals with chronic respiratory diseases other than COPD (i.e., interstitial lung disease, bronchiectasis, cystic fibrosis, asthma, pulmonary hypertension, lung cancer, lung volume reduction surgery, and lung transplantation) has demonstrated improvements in symptoms, exercise tolerance, and quality of life. This effort is in the direction to incorporate rehabilitation early in the management of tuberculosis so that the patients in addition to being cured are holistically managed.

USAID India funded, and The Union led iDEFEAT project is supporting the CoE RBIPMT, New Delhi in establishing a centre of excellence in pulmonary rehabilitation for people affected with TB. The purpose of this SOP is to integrate pulmonary rehabilitation in the standard of care for individuals with TB, with a specific focus on improving overall well-being of the affected individual. This document will be a guide to all healthcare professionals, including physicians, nurses, physical therapists, and other staff involved in the care and rehabilitation of patients with TB as well as chronic respiratory diseases.

The aims of pulmonary rehabilitation are:

1. Decrease of physical and psychological impairment due to the disease
2. Increase in physical and mental fitness and performance
3. Maximal social reintegration of the patient and self-sufficiency.

Pulmonary rehabilitation is implemented by a dedicated, interdisciplinary team including physicians/health care professionals, physiotherapists/respiratory therapists, nurses, psychologists, nutritionists, occupational therapists, and social workers. The intervention should be individualized to the unique needs of the patient, based on initial and ongoing assessments, including disease severity, complexity, and comorbidities. Although pulmonary rehabilitation is a defined intervention, its components should be integrated throughout the clinical course of a patient’s disease. Pulmonary rehabilitation may be initiated at any stage of the illness. The programme is good for one-to-one guidance, but group exercises can be incorporated on the need basis.

Infrastructure

The Pulmonary Rehabilitation Centre (PRC) should be located in or close to a hospital. 

To set up a dedicated pulmonary rehabilitation unit the following are the basic requirements:

1. An independent space with good ventilation (6-12 Air Change per Hour).

2. Area of 1000 square feet (20 x 50 feet room). This space will house the clinic room, counselling, physiotherapy section, data management and other facilities.

3. A corridor 30-35 meters, non-slippery, free from movement of people, fitted with hand rails on either side and also with oxygen ports and chairs alongside.

4. Area for hand washing/washroom.

In order to establish a pulmonary rehabilitation unit, the following equipment are required. 

In order to get the pulmonary rehabilitation programme running at any site, the following are the required personnel:

1. One Doctor

2. One Nurse 

3. Two Physiotherapists 

4. One Yoga trainer (Desirable)

5. One Dietician 

6. One Psychologist (Desirable)
7. One Scheduler/ recording person/ an administrative person/ nurse (can be an asset in case of any female patient)
8. One helper/ orderly person

The follow-up sessions will focus on maintaining the effects achieved and the progress made. It will be based on the improvement in patient-reported outcome measures and the patient's signs and symptoms and vital parameters.

• At the end of 12 sessions, information on patient experience, needs and satisfaction, during and after the pulmonary rehabilitation to be collected and recorded.

• The clients to be provided with a comprehensive discharge plan, including medication instructions and follow-up appointments.

• The follow up sessions to be planned every month and will be assessed on basis of the discharge plan

• On basis of the outcome of the pulmonary rehabilitation programme help the client in beneficial vocational training

During the pulmonary rehabilitation programme sessions, group talks should be arranged to educate the participants on the importance and benefits of the pulmonary rehabilitation programme. The information may be imparted through visuals using the LCD screen or televisions, through group talks or individual counselling. Education should focus on:

a.   TB:

• Educate clients about TB transmission, prevention, and the importance of medication adherence including avoidance of irritants
• Educate the clients about the possible adverse reactions to the drugs and also about the importance to inform the same to the treatment supervisors.
• Educate them on the importance of having a balanced diet

b.   Self-Management: 

• Teach the clients self-monitoring of symptoms, exacerbation recognition and when to contact the health care provider
• Teach them proper use of prescribed inhalers or respiratory devices
• Teach them technique of postural drainage in case of the post treatment sequalae
• Educate them on hazards of smoking, drinking or tobacco consumption in any form
• Importance of motivating oneself and encouraging them for vocational training
• Use of meditation and yoga in daily regime

It is important to maintain a safe and healthy environment for our clients and staff and so infection control needs to be an essential aspect of our daily operations. It is crucial that we remain vigilant and proactive in preventing the spread of infection. There are some points to be kept in mind when we are running pulmonary rehabilitation unit like:

• Adherence to Air borne infection control guidelines needs to be followed.
• Regular screening of participants for viral infections and if required give them a break from the pulmonary rehabilitation programme till they recover acceptably.
• Protective equipment for the working staff as per the programmatic guidelines should be provided
• Emphasize strict hand hygiene for healthcare workers and visitors
• Adequate windows and doors should be there in the facility ensuring cross ventilation.
• In case of inadequate cross ventilation, adequate fans and exhaust fans should be there and in working condition to ensure adequate air changes per hour.  UVGI as per the requirement also depending of the facility may be made available.
• Equipment sterilization techniques like use of UV towers that can be linked to the mobile Apps.

Documentation should be done on a paper-based format as it makes it easier for the people involved to compare and evaluate the data from different visits of the clients. It includes:

• Patient card/ discharge card
• Diary for record keeping
• Registers
• Excel sheet (electronic mode)

The following indicators may be used to evaluate the progress made by the pulmonary rehabilitation programme:

• (a). Number of people eligible for Pulmonary Rehabilitation Program
• (b). Out of (a), proportion of people took / enrolled in Pulmonary Rehabilitation Program
• (c) Out of (b), proportion of people completed Pulmonary Rehabilitation Program
• (d). Out of (c), proportion of people with an improved outcome. 
•  

Outcomes of individual clients may be documented as follows:

1. V.V. Banu Rekha, Rajeswari Ramachandran, K.V. Kuppu Rao, et al. Assessment of long-term status of sputum positive pulmonary tb Patients successfully treated with short course chemotherapy. Ind J Tub 2009; 132-40.

2. A D Harries et al. Successfully treated but not fit for purpose: paying attention to chronic lung impairment after TB treatment. INT J TUBERC LUNG DIS 20(8):1010–1013

3. Singh S K, Naaraayan A, Acharya P, et al. Pulmonary Rehabilitation in Patients with Chronic Lung Impairment from Pulmonary Tuberculosis. Cureus. 2018; 10(11): e3664.

4. Krishan Gupta, Raj Kumar and S.N. Gaur. Effect of a Domiciliary Pulmonary Rehabilitation Programme on Disability in Patients with Interstitial Lung Diseases. Ind J Chest Dis Allied Sc.

5. Dr. Yatin Dholakia. Forum. Indian J Tuberc 2010; 57:57

6. Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. C.F. Donner, P. Howard. Pulmonary rehabilitation In chronic obstructive pulmonary disease (COPD) with recommendations for Its use. Working Group Report. Eur Reaplr J 1992, 5, 266-275