American Thoracic Society(ATS) and the European Respiratory Society (ERS) have adopted a new definition of pulmonary rehabilitation: “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 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".45

 As per the practice guidelines of the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation (ACCP/AACVPR), "Any stable patient suffering from respiratory symptoms and having a chronic lung disease should consider pulmonary rehabilitation".46 

Pulmonary tuberculosis (PTB) may result in long-term bronchial and parenchymal structural abnormalities even with appropriate treatment, which results in decreased quality of life. 

Minimizing symptom load, optimizing exercise performance, encouraging autonomy, raising involvement in daily activities, improving (health-related) quality of life, and bringing about long-term health-improving behavior change are among the objectives of pulmonary rehabilitation. 

1. Frequency and duration of PR in PTB sequelae47

Pulmonary rehabilitation programme of 6–12 weeks are recommended.
Pulmonary rehabilitation regimens should include at least twice-weekly supervised sessions. A third session of specified exercise can be completed unsupervised.

2. Equipment required for PR
• Treadmill
• Stationary bicycle
• Access to stairs or step box
• Access to stairs or step box
• Arm crank ergometer
• Hand weights
• Resistive exercise bands

3. Components of PR
i. Breathing techniques
ii. Airway clearance techniques
iii. Exercise training
iv. Yoga 
v. Education
vi. Psychological support
vii. Nutritional advice

1. Breathing techniques48

Pursed lip breathing:
It reduces shortness of breath and gives a quick and easy approach to slow down the rate of breathing, making each breath more effective.

When short of breath, pursed lip breathing helps to get more oxygen into the lungs and calms down and to have better breath control.
Technique: 
•    To sit down in a chair and relax the neck and shoulder muscles.
•    Breathe in slowly through the nose, making sure to keep the mouth closed.
•    " Pucker, or "purse" the lips as if going to whistle or gently blow out a candle.
•    And then breathe out, or exhale, all of the air in the lungs through mouth slowly and gently through pursed lips.
•    Try to breathe out longer than inhalation.

Continue to repeat this exercise of slowly inhaling through the nose and exhaling through pursed lips until the breath becomes normal. Pursed lip breathing works by moving oxygen into your lungs and carbon dioxide out of your lungs. This approach helps to keep the airways open for a longer duration, so that the trapped air in the lungs is removed by lowering the breathing rate and thus reducing shortness of breath.

Diaphragmatic breathing: 
It also known as abdominal/belly breathing. It helps to use the diaphragm correctly while breathing to - strengthen the diaphragm, decrease the work of breathing by slowing the breathing rate, decrease oxygen demand, use less effort and energy to breathe.

Technique:  
• Lie supine on a flat surface or in bed, with the knees bent and head supported.
• Place one hand on upper chest and the other just below the rib cage. This will allow to feel the diaphragm movement on breathing. 
• Breathe in slowly through the nose so that the abdomen moves out, causing the hand to rise. The hand on the chest should remain as still as possible. Tighten the abdominal muscles, so that the abdomen moves in, causing the hand to lower as you exhale through pursed lips. The hand on the upper chest should remain as still as possible.

2. Airway clearance techniques (ACT):49

1.  Active cycle of breathing technique (ACBT):
It is an active breathing technique performed by the patient and can be used to mobilize and clear excess pulmonary secretions and to generally improve lung function. It, Loosen and clear secretions from the lungs which helps to reduce the risk of chest infections, improves ventilation in the lungs, Improve the effectiveness of a cough.

ACBT consists of three main phases:
i.    Breathing Control
ii.    Deep Breathing Exercises or Thoracic Expansion Exercises
iii.    Huffing or Forced Expiratory Technique (FET)

2.  Autogenic drainage: 
It is an airway clearance technique that is characterized by breathing control, where the individual aims to adjust the rate, depth, and location of lung volumes during respiration. It mobilizes, loosens, and moves secretions in three steps, towards the bigger central airways by breathing at different lung volumes. It consists of 3 phases,
Phase 1: low volume breaths to mobilize secretions from the peripheral airways (unsticking)
Phase 2: medium(tidal) volume breaths to collect mucus from the middle airways (collecting)
Phase 3: large volume breaths enabling expectoration from central airways (evacuation)

3.  Chest percussion therapy (CPT): 
It is an ACT, that typically involves the assistance of another individual (e.g., caregiver, trained family member, or respiratory therapist) to manually perform chest percussion on a patient’s chest wall. Chest percussion is defined as manually clapping on a person's chest wall in order to break up mucus and prevent accumulation. For this technique to be effective, however, clapping must be conducted in a repetitive and rhythmic beat sequence to create vibrations that help transfer mucus from the tiny airways to bigger ones, where it is more easily coughed up.

4.  Huffing coughs: 
This is a type of coughing that moves mucus from the lungs and is done in combination with other airway clearance techniques. Huffing coughs involves breathing in, holding the breath to allow the air to separate the mucus from the lung walls, and then exhaling forcefully to remove the mucus.

5.  Positive expiratory pressure (PEP) - This is a breathing technique that uses a mask or handheld device to help patients break up mucus and move it out of the lungs and airway. When the patient inhales using these devices, air can pass freely; but, when they exhale, resistance is created, allowing air to get behind the mucus and more effectively break it up.

3.Exercise training50

Post TB squeal patients might have decreased effort tolerance, cachexia, asthenia and muscle fatigue. Therefore, exercise training should be included as a part of pulmonary rehabilitation. Exercise trainings are – endurance training and strength/resistance training.  The goal is to improve patients' aerobic capacity and muscle strength.

1. Endurance training: The crux of endurance training is the conditioning of muscles of ambulation and augmentation of cardiorespiratory fitness, translating to an increase in physical activity with decreased dyspnea and fatigue. Cycling and walking exercises are the 2 common forms of endurance training.
   Lower limb training includes leg-ergometry and treadmill walking. Training of the upper limbs includes arm-ergometry and free weights. Frequency of three to five times per week is recommended for endurance exercise training at an intensity of more than 60% maximal work rate for 20 to 60 minutes.

2.Intervaltraining: The alternate option to standard endurance training in individuals who have difficulty with continuous training. Interval training consists of periods of intense exercise followed by rest or lower intensity training. It also enables for the majority of the benefits of endurance training while minimizing dyspnea and tiredness.

3.Resistance training/strength training: It involves training with resistive loads with repetitions, and loads are increased progressively to achieve maximal benefits. Resistance training is associated with less dyspnea than endurance exercise, and patients may be able to handle it better in certain cases. Resistance training also helps improve muscle mass and bone mineral density. As part of resistance training, the American College of Sports Medicine suggests performing one to three sets of eight to twelve repetitions on two or three days a week to increase muscle strength. Approximately 60–70% of the maximal number of repetitions is deemed appropriate for the first load.
 

4. Yoga51

Yoga is an ancient pre-Vedic science and an integral part of the Indian culture. The ideal functioning of the body and mind is based on the physical, physiological, mental, and spiritual well-being, according to yoga philosophy. Yoga has long been recognized as a psychosomatic exercise for overall health. The eight limbs or aspects of Ashtanga yoga form the foundation of yoga.

Components of yoga used in PR
1.    Asana (yoga postures) – helps to build strength, flexibility, cardio-respiratory response.
2.    Pranayama (yoga breathing) – helps to control breath, reduce gas trapping.
3.    Dharana (meditation) – helps to control stress and regulate emotion.

5.Education

Educating the patient and the family regarding – bronchial hygiene, cough etiquette, proper use of medications including oxygen, benefits of exercise, leisure, travel, sexuality, energy conservation, prevention of respiratory infections.

6.Psychological support and Nutritional advice

It is dealt in respective chapters.