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Important Notice

Case report
Year : 2023 | Month : September | Volume : 17 | Issue : 9 | Page : YD01 - YD04 Full Version

Efficacy of Pulmonary Rehabilitation in Pulmonary Tuberculosis Sequelae with Cystic Bronchiectasis and Pulmonary Hypertension

Published: September 1, 2023 | DOI:
Pooja Ramesh Tiwari, Vishnu Diwakar Vardhan, Vishakha Tayade, Moli Jain

1. Intern, Department of Cardio-Respiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 2. Professor, Department of Cardio-Respiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 3. Resident (MPT), Department of Cardio-Respiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 4. Resident (MPT), Department of Cardio-Respiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.

Correspondence Address :
Pooja Ramesh Tiwari,
Plot No. 10, Sad Guru Nagar, Paloti Street, Wardha, Maharashtra, India.


Cystic bronchiectasis, also known as saccular bronchiectasis (a severe type of bronchiectasis), is a condition that occurs as a complication and sequelae after pulmonary Tuberculosis (TB). There is chronic permanent dilation of bronchi that occurs after destructive changes in elastic and muscular layers of bronchial walls which further leads to the ballooning of bronchi and difficulty in clearing secretions with recurrent infection of the respiratory tract. Pulmonary hypertension is another major complication after bronchiectasis which affects pulmonary circulation. A 44-year-old female reported to the physiotherapy department with cystic bronchiectasis and pulmonary hypertension. The positive symptoms were chronic cough with mucoid sputum, low-grade fever, chest pain, breathlessness (modified Medical Research Council (mMRC) grade III), and easy fatiguability. The goals were set and inpatient Pulmonary Rehabilitation (PR) started with the aim of reducing burdening of symptoms and promoting the Quality of Life (QoL). The therapeutic interventions were splinted coughing techniques, deep breathing exercises, thoracic expansions, postural correction exercises, dyspnoea relieving positions, strength training, and pacing techniques. After rehabilitation the ventilation along with strength improved, dyspnoea was reduced, and exercise tolerance was increased.


Dyspnoea, Physiotherapy, Quality of life, Therapeutic interventions, Ventilation

Case Report

A 44-year-old female patient, a farmer by occupation, visited the medicine department with chief complaints of breathlessness (mMRC grade III), dry cough, and early fatigue for 1 year. The current symptoms are described in (Table/Fig 1). She was diagnosed with pulmonary TB, nine years back and took medications for eight months. For three years she had a similar episode of chest pain, cough, fever, and breathlessness and was diagnosed with post-TB sequelae, for which she again took medication for six months. After all suggested investigations were done shown in [Table/Fig-2,3], the patient was diagnosed with post-TB with cystic bronchiectasis and pulmonary hypertension. After the diagnosis patient was referred to the Department of Physiotherapy for further management.

The patient was conscious, well-oriented, cooperative, afebrile, haemodynamically stable, and relates most of her medical history. She was ectomorphic, with a Body Mass Index (BMI) of 17 kg/m2. She was on three liters of oxygen via nasal prongs, and the use of accessory muscles while breathing was observed. Respiratory examination revealed supraclavicular hollowness, barrel chest shape, and positive trail’s sign as the trachea deviates to the left-side. Chest expansion was reduced at the nipple and xiphisternum levels, respectively. On percussion, a dull note was present over the left lung in the supramammary, mammary and inframammary regions. On auscultation, the air entry was reduced in the left upper, middle, and lower zones and right lower zones.

Physiotherapy management: The physiotherapy prescription started with the education of the patient and family about the present condition. Explaining to them the problems regarding their condition, goals to overcome it, and the importance of exercise therapy. The two weeks of inpatient rehabilitation are detailed in (Table/Fig 4).

The outcome measures were taken on the first day of referral, then after two weeks of physiotherapy rehabilitation, and after one week while follow-up. So, the pre, post, and follow-up are given in (Table/Fig 6). On the follow-up the dyspnoea was relieved from mMRC grade III to mMRC grade I, and the patient was able to cover more distance without getting fatigued in test-retest on a Six-Minute Walk Test (6MWT) further improvement was measured in the modified Borg scale (1) followed by chest pain reduction while activity and on rest for that was used Numeric Pain Rating Scale (NPRS) (2) along with the improvement in quality of life was assessed using World Health Organisation Quality of Life (WHOQoL) (3).


Pulmonary TB is a major global health challenge and the second leading cause of infectious disease-related deaths, affecting individuals of all ages. Even after recovery, patients may still experience sequelae, with 295.9 cases per 100,000 people experiencing structural lung damage leading to physiological impairments and disability (4). Cystic bronchiectasis is a persistently progressive condition characterised by the destruction of the muscular and elastic components of the lungs, resulting in wider and damaged large airways. This condition can occur after an infection or fibrotic changes in lung tissues and is more prevalent in females, with significant morbidity (5). Pulmonary hypertension is a rare but critical condition that affects pulmonary circulation, with a prevalence of 10-52 cases per million. Individuals with pulmonary hypertension typically experience primary symptoms of breathlessness, decreased functional abilities, and reduced QoL (6).

Post-Tuberculosis Lung Damage (PTLD) presents with both obstructive and resistive airway abnormalities, resulting in increased respiratory symptoms and decreased QoL. The presence of chest pain and breathlessness has been closely associated with low QoL, influencing physical, psychological, and social areas of health in patients with pulmonary TB sequelae. This condition has been linked to depression, severe hypoxaemia, age, socio-economic class, and physiological well-being (7). Although the specific condition is not curable, medication and physiotherapy can reduce the burden of the condition and promote life expectancy (8).

PR (Pulmonary Rehabilitation) is a multidisciplinary program for patients with respiratory impairment that compromises their clinical and functional status, affecting their QoL. In a study conducted on eight patients with TB sequelae, PR was found to have a positive impact on health-related QoL and aerobic capacity, assessing disability, exercise capacity, and participation. The study confirms that PR improves health status associated with unexpected haematosis or chest pain and other patient-related outcomes (9).

A study was conducted in 2019 to see the efficacy of PR on TB sequelae, an old disease with a new approach. This rehabilitation focused on aerobic exercises for eight weeks held three times a week, with training intensity ranging from 60-90% of maximum oxygen intake. The results were encouraging, with a 1.7 mL/kg/min increase in peak oxygen consumption (VO2) and a 63.6 m increase in the 6MWT distance. Hence, positive feedback was achieved by improving the physical and functional status of patients with TB, as well as providing psychological support, shortening the convalescent period, and allowing patients to return to work sooner (10). A study was conducted in 2022 to assess the efficacy of exercise therapies in patients with bronchiectasis regarding pulmonary functions, exercise capacity, and QoL. During eight weeks of rehabilitation, the key outcomes were Incremental Shuttle Walk Distance (ISWD) and 6-MWD. The secondary outcomes were Forced Expiratory Volume in one second (FEV1), St. George’s Respiratory Questionnaire (SGRQ), and Leicester Cough Questionnaire (LCQ). The results concluded that PR increases exercise capacity and lung function (particularly FEV1) in individuals with bronchiectasis when compared to normal treatments (11). Patients suffering from respiratory symptoms typically have respiratory muscle weakness. Inspiratory Muscle Training (IMT) has been found to improve inspiratory muscle strength, endurance, functional exercise capacity, dyspnoea, and QoL when used alone. At equivalent work rates, IMT paired with exercise training may result in higher decreases in dyspnoea intensity than exercise training alone (12).

In cases of pulmonary hypertension, breathlessness can be a problem in rehabilitation. Patients with major risk should be monitored properly, and this could be achieved in supervised PR programs. PR provides patients with both physiotherapy and nursing support. The personalised, individualised approach allows the optimum rehabilitation solution to be delivered to patients based on their needs (13). There are two ways to measure outcomes: subjectively and objectively. In this case, both outcomes were taken into consideration. The main focus was on the 6MWT and retest, which shows reliability and significance in patients with respiratory problems (14). Almost every respiratory condition affects QoL. Therefore, present study followed the World Health Organisation (WHO) definition of QOL and used the WHOQoL scale. This was because they are universally accepted and accepted and hence reliable to use as a multidimensional questionnaire (3).


The PR in post-TB sequelae with cystic bronchiectasis and pulmonary hypertension was effective and clinically significant in improving oxygenation and ventilation by removing oxygen support, increasing strength, relieving dyspnoea, improving exercise capacity, and ultimately improving patients’ QoL. This case report provides an integrated management plan for Cystic Bronchiectasis as a post-TB sequela. The patient achieved full recovery while rehabilitation and symptoms were managed, reducing the burden of the disease and promoting QoL. The intervention and its outcomes heavily rely on physiotherapy skills and knowledge, and more research is needed to determine the effectiveness of physiotherapy interventions in pulmonary hypertension.


Borg Rating of Perceived Exertion (RPE) scale | Occupational Medicine | Oxford Academic [Internet]. [cited 2023 Jan 25]. Available from: [crossref]
McCaffery M, Beebe A. Numeric Pain Rating Scale Instructions.pdf [Internet]. 1989 [cited 2023 Aug 19]. Available from:
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Pathan A, Yadav V, Jain M, Saifee S. An Early Comprehensive Physiotherapy Approach towards Reconditioning of Patient with Empyema Thoracis: A Case Study. J Pharm Res Int. 2021;33(59B):108-12. [crossref]
Macfarlane L, Kumar K, Scoones T, Jones A, Loebinger MR, Lord R. Diagnosis and management of non-cystic fibrosis bronchiectasis. Clin Med. 2021;21(6):e571-77. [crossref][PubMed]
Keen C, Fowler-Davis S, McLean S, Manson J. Physiotherapy practice in pulmonary hypertension: physiotherapist and patient perspectives. Pulm Circ. 2018;8(3):2045894018783738. [crossref][PubMed]
Ibrahim S, Manu MK, James BS, Kamath A, Shetty RS. Health Related Quality of Life among patients with Chronic Obstructive Pulmonary Disease at a tertiary care teaching hospital in southern India. Clin Epidemiol Glob Health. 2021;10:100711. [crossref]
Meghji J, Lesosky M, Joekes E, Banda P, Rylance J, Gordon S, et al. Patient outcomes associated with post-tuberculosis lung damage in Malawi: A prospective cohort study. Thorax. 2020;75(3):269-78. [crossref][PubMed]
Jones R, Kirenga BJ, Katagira W, Singh SJ, Pooler J, Okwera A, et al. A pre-post intervention study of pulmonary rehabilitation for adults with post-tuberculosis lung disease in Uganda. Int J Chron Obstruct Pulmon Dis. 2017;12:3533-39. [crossref][PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2023/60872.18323

Date of Submission: Oct 17, 2022
Date of Peer Review: Dec 08, 2022
Date of Acceptance: Feb 01, 2023
Date of Publishing: Sep 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Oct 21, 2022
• Manual Googling: Dec 15, 2022
• iThenticate Software: Jan 31, 2023 (5%)

ETYMOLOGY: Author Origin


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