Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis

doi:10.1590/S1806-37562016000000226

ISSN 1806-3713

http://dx.doi.org/10.1590/S1806-37562016000000226

ABSTRACT

The role of tuberculosis as a public health care priority and the availability of diagnostic tools

to evaluate functional status (spirometry, plethysmography, and DLCO determination),

arterial blood gases, capacity to perform exercise, lesions (chest X-ray and CT), and

quality of life justify the effort to consider what needs to be done when patients have

completed their treatment. To our knowledge, no review has ever evaluated this topic

in a comprehensive manner. Our objective was to review the available evidence on this

topic and draw conclusions regarding the future role of the “post-tuberculosis treatment”

phase, which will potentially affect several million cases every year. We carried out a

non-systematic literature review based on a PubMed search using specic keywords

(various combinations of the terms “tuberculosis”, “rehabilitation”, “multidrug-resistant

tuberculosis”, “pulmonary disease”, “obstructive lung disease”, and “lung volume

measurements”). The reference lists of the most important studies were retrieved in

order to improve the sensitivity of the search. Manuscripts written in English, Spanish,

and Russian were selected. The main areas of interest were tuberculosis sequelae

following tuberculosis diagnosis and treatment; “destroyed lung”; functional evaluation

of sequelae; pulmonary rehabilitation interventions (physiotherapy, long-term oxygen

therapy, and ventilation); and multidrug-resistant tuberculosis.The evidence found

suggests that tuberculosis is denitively responsible for functional sequelae, primarily

causing an obstructive pattern on spirometry (but also restrictive and mixed patterns),

and that there is a rationale for pulmonary rehabilitation. We also provide a list of variables

that should be discussed in future studies on pulmonary rehabilitation in patients with

post-tuberculosis sequelae.

Keywords: Tuberculosis/complications; Tuberculosis/rehabilitation, Tuberculosis/therapy;

Quality of life; Diagnostic imaging; Respiratory function tests.

Is there a rationale for pulmonary

rehabilitation following successful

chemotherapy for tuberculosis?

Marcela Muñoz-Torrico

1

, Adrian Rendon

2

, Rosella Centis

3

, Lia D’Ambrosio

3,4

,

Zhenia Fuentes

5

, Carlos Torres-Duque

6

, Fernanda Mello

7

, Margareth Dalcolmo

8

,

Rogelio Pérez-Padilla

9

, Antonio Spanevello

10,11

, Giovanni Battista Migliori

3

Correspondence to:

Giovanni Battista Migliori. World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione Salvatore Maugeri, Istituto di Ricovero e Cura a

Carattere Scientico, Via Roncaccio, 16, 21049, Tradate, Italia.

Tel.: 39 0331 829404; Fax: 39 0331 829402. E-mail: giovannibattista.migliori@fsm.it

Financial support: None.

INTRODUCTION

The World Health Organization (WHO) estimated that 3.3% of the new cases

of tuberculosis and 20% of the previously treated cases of the disease are due

to multidrug-resistant tuberculosis (MDR) strains of Mycobacterium tuberculosis

worldwide in 2014. The highest prevalences of MDR tuberculosis (MDR-TB) have

been reported in Eastern European and Central Asian countries, although relatively

high prevalence rates have been described in Latin America. As of today, the “world

record” MDR-TB prevalence has been described in Belarus (34% among new cases

and 69% among retreatment cases), where 29% of the cases are reported to be

extensively drug-resistant tuberculosis (XDR-TB).

(1)

It is unfortunately well known that outcomes of MDR-TB and XDR-TB cases (particu-

larly those with a resistance pattern beyond XDR-TB) are poor, since the treatment

success rate is below 20% and the failure and death rates combined are 49%.

(2,3)

The WHO has recently published two core documents addressing the critical

importance of preventing the emergence of drug resistance, both underlining the

relevance of managing MDR-TB adequately.

(1,4-8)

The WHO action framework “Towards

tuberculosis elimination for low-incidence countries” presents eight priority action

areas, two of which are focused on, namely, (action #5) optimizing the management of

MDR-TB and (action #7) investing in research on new diagnostic tools and drugs.

(1,4,6,9)

1. Clínica de Tuberculosis, Instituto

Nacional de Enfermedades

Respiratorias – INER – Ciudad de

México, México.

2. Centro de Investigación, Prevención

y Tratamiento de Infecciones

Respiratorias, Hospital Universitario,

Universidad de Monterrey, Monterrey,

México.

3. WHO Collaborating Centre for TB and

Lung Diseases, Fondazione Salvatore

Maugeri, Istituto di Ricovero e Cura a

Carattere Scientico – IRCCS – Tradate,

Italia.

4. Public Health Consulting Group SAGL,

Lugano, Switzerland.

5. Servicio de Neumología, Hospital

General Dr. José Ignacio Baldó, El

Algodonal, Caracas, Venezuela.

6. Fundación Neumológica Colombiana,

Universidad de La Sabana, Bogotá,

Colombia.

7. Instituto de Doenças do Tórax,

Universidade Federal do Rio de Janeiro,

Rio de Janeiro (RJ) Brasil.

8. Centro de Referência Hélio Fraga,

Escola Nacional de Saúde Pública

Sergio Arouca, Fundação Oswaldo Cruz,

Rio de Janeiro (RJ) Brasil.

9. Clínica del Sueño, Instituto Nacional de

Enfermedades Respiratorias – INER –

Ciudad de México, México.

10. Unità di Pneumologia, Fondazione

Salvatore Maugeri, Istituto di Ricovero

e Cura a Carattere Scientico – IRCCS –

Tradate, Italia.

11. Dipartimento di Medicina Clinica e

Sperimentale, Università dell’Insubria,

Varese, Italia.

Submitted: 28 July 2016.

Accepted: 1 September 2016.

Study carried out under the auspices

of the World Health Organization

Collaborating Centre for Tuberculosis and

Lung Diseases, Fondazione Salvatore

Maugeri, Istituto di Ricovero e Cura a

Carattere Scientico – IRCCS – Tradate,

Italia.

J Bras Pneumol. 2016;42(5):374-385

374

REVIEW ARTICLE

Muñoz-Torrico M, Rendon A, Centis R, D’Ambrosio L, Fuentes Z, Torres-Duque C, et al.

However, the scientic and programmatic focus is

presently on diagnosis and treatment of the disease,

whereas post-cure follow-up is seen as an approach

to evaluate the proportion of relapse, particularly in

MDR-TB/XDR-TB cases.

The role that tuberculosis plays as a public health

care priority, as well as the importance of diagnostic

tools being available in order to evaluate the patients

thoroughly, by means of their functional status—via

spirometry, plethysmography, and determination of

DLCO —arterial blood gas analyses, their capacity to

perform exercise—via the six-minute walk test (6MWT)—

the description of their lesions—via chest X-rays (CXRs)

and CT—and their quality of life (QoL)—via the Saint

George’s Respiratory Questionnaire (SGRQ)—justies

the effort to consider what needs to be done when

patients have completed their treatment successfully.

This vision has ethical, clinical, organizational,

programmatic, and economic implications.

To our knowledge, the follow-up of tuberculosis

patients who completed their treatment has never

been reviewed in a comprehensive manner in the

literature. Therefore, the objective of the present study

was to review the available evidence on this topic and

to draw some conclusions regarding the future role

of the “post-tuberculosis treatment” phase, which will

potentially have an impact on several million cases

every year around the globe.

METHODS

We carried out a non-systematic review of the

literature based on a PubMed search using specic

keywords, including various combinations of the terms

“tuberculosis”, “rehabilitation”, “MDR-TB”, “pulmonary

disease”, “obstructive lung disease”, and “lung volume

measurements”. The reference lists of the most

important studies were also retrieved in order to

improve the sensitivity of the research. Manuscripts

written in English, Spanish, and Russian were selected.

The main areas of interest that we identied in order

to describe the topic were as follows:

1.

Tuberculosis sequelae following diagnosis and

treatment of tuberculosis

2. Destroyed lung

3. Functional evaluation of sequelae

4.

Pulmonary rehabilitation (PR) interventions, such

as physiotherapy, long-term oxygen therapy

(LTOT), and ventilation

5. MDR-TB

After describing each of these areas of interest, we

will provide a summary of the evidence compiled from

the literature search (Table 1) and concluding remarks.

TUBERCULOSIS SEQUELAE FOLLOWING

DIAGNOSIS AND TREATMENT OF

TUBERCULOSIS

Although the potential role of PR has been clearly

underlined in a study discussing the role of the

new WHO recommendations on shorter treatment

regimens,

(10)

the concept that rehabilitation is a

component of tuberculosis treatment is as old as that of

sanatoria.

(11,12)

In 1964, Chapman and Hollander wrote

that, based on their experience with 454 patients with

active tuberculosis “placed on a program of intensive

physical exercise, combined with chemotherapy,” “the

concept of minimum exercise and prolonged bed rest

in the hospital and a prolonged convalescent period

after discharge is no longer justied.”

(12)

In 2006, a group of authors in India

(13)

prospectively

studied the clinical presentation and predictors of

outcome in 116 patients with acute exacerbations of

COPD who had to be admitted to the ICU and found

that 28.4% of those had had pulmonary tuberculosis

previously. Among those patients, some required

invasive mechanical ventilation and a few died. The

authors concluded that “an intriguing relationship”

existed among smoking, pulmonary tuberculosis, and

COPD “which merits further study.”

(13)

In 2010, Jordan et al.

(14)

wrote that “the global

prevalence of bronchiectasis, a recognized sequela

of tuberculosis, is unknown, but is by no means

insignicant. The pathophysiology of chronic airow

obstruction in both of these diseases is poorly under

-

stood, but it is associated with an accelerated rate of

loss in pulmonary function.”

Hassan and Al-Jahdali

(15)

reported that “in addition

to its acute clinical consequences, patients with

pulmonary tuberculosis may be left with signicant

long-term sequelae,” “associated with considerable

morbidity, mortality, and health expenditure,” and

commented that both obstructive and restrictive

functional abnormalities were present.

Shah and Reed

(16)

described, among the commonest

complications of tuberculosis, “mycetomas developing

within residual tuberculosis cavities, impaired pulmonary

function, or focal neurologic decits from tuberculomas,”

and, therefore, “public health tuberculosis programs and

health systems require additional resources to provide

comprehensive tuberculosis and post-tuberculosis care.”

Bansal and Prasad

(17)

commented that “COPD, intersti-

tial lung disease, tuberculosis, and lung cancer together

are the leading causes of morbidity and mortality,” which

are “increasing all over the world”; they also stated

that “early fatigue and breathlessness” make patients

“socially isolated and depressed”. Functional disability

and repeated hospitalizations reduce the efciency

of the patients at home and at work place, being

associated with increased expenditures and utilization of

health care systems, which results in a socioeconomic

burden. PR, an evidence-based, multidisciplinary, and

comprehensive non-pharmacological intervention, has

emerged as a recommended standard of health care

for patients suffering from respiratory diseases. PR

is advised for patients with chronic lung conditions

who have dyspnea or other respiratory symptoms,

reduced exercise tolerance, restriction in activities, or

impaired health status despite optimal pharmacological

treatment. Early leaders observed two centuries ago

375

J Bras Pneumol. 2016;42(5):374-385

Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis?

Table 1. Summary of the major studies that performed functional evaluation of patients with pulmonary tuberculosis.

Authors, year Study location

(name)

a

Participants

b

(n)

Cases investigated Investigations

performed

Major functional findings Conclusions

Rhee et al.,

2013

(21)

South Korea 595 History of PTB Spirometry;

CXR, CT

Mean number of lobes involved: 2.59 ± 0.05. Pleural

thickening in 54.1% of the patients. Signicant correlation

between the number of lobes involved and FVC% (r = −0.24;

p < 0.001) and FEV

1

% (r = −0.21; p < 0.001)

Decreased lung function, exacerbations, and progressive

decline of FEV

1

were found in the patients with PTB “destroyed

lung”

Lee et al.,

2003

(22)

South Korea 21 CAO patients

vs. 11 COPD

patients

History of PTB Spirometry Patients with CAO due to PTB vs. COPD patients: FVC

(2.14 ± 0.73 L vs. 2.60 ± 0.69 L; p < 0:05); FVC% (57.97% ±

14.8% vs. 70.07% ± 14.8%; p < 0:01); and response rate/%

of change in post-bronchodilator FEV

1

signicantly lower

in CAO patients

Bronchodilator therapy useful to treat CAO

Báez-Saldaña et

al., 2013

(23)

Mexico 127 Cured PTB CXR and

spirometry

123 patients (96.85%) with CXR abnormalities; degree

of CXR abnormalities independently associated with

decreases in FVC (0.07 L; 95% CI: −0.01 to −0.04); FEV

1

(0.07 L; 95% CI: −0.10 to −0.05); FVC% (2.48; 95% CI: −3.45

to −1.50); and FEV

1

% (2.92; 95% CI: −3.87 to −1.97)

Spirometric results associated with degree of abnormalities

on CXR assessed by a simple scoring method

Willcox et al.,

1989

(25)

USA 71 History of PTB Spirometry 48 (68%) with evidence of airway obstruction Treated PTB is a cause of signicant CAO.

Hnizdo et al.,

2000

(26)

South Africa 2,137 (1 TB

episode); 366

(2 TB episodes);

and 96 (with 3 or

+ TB episodes)

History of PTB Spirometry Chronic airow impairment (FEV

1

< 80% of predicted)

detected in 18.4% (1 TB episode); 27.1% (2 TB episodes);

and 35.2% (3 or + TB episodes)

PTB can cause chronic impairment of lung function, which

increases incrementally with the number of TB episodes

Amaral et al.,

2015

(27)

Multinational (BOLD

study)

c

14,050 Self-reported history

of TB

Spirometry Airow obstruction: aOR = 2.51 (95% CI: 1.83-3.42); and

airow restriction: aOR = 2.13 (95% CI: 1.42-3.19)

History of TB associated with both airow obstruction and

spirometric restriction

Jung et al.,

2015

(28)

South Korea

(KNHANES study

2008-2012)

c

14,967 History of PTB and no

sequelae on CXR

CXR and

spirometry

822 (5.5%) with a history of PTB vs. 14,145 (94.5%) without

TB history: FVC% (84.9 vs. 92.6), FEV

1

% (83.4 vs. 92.4),

and FEV

1

/FVC% (73.4 vs. 77.9); among the subjects with

normal CXR, those with a history of PTB (296; 2.3%) had

signicantly lower FEV1% and FEV1/FVC than did those

without a TB history (90.9 vs. 93.4 and 76.6 vs. 78.4,

respectively)

Subjects with prior PTB, inactive lesions on CXR, or no TB

sequelae can show impaired pulmonary function and increased

respiratory symptoms

Sailaja et al.,

2015

(29)

India 56 Cured PTB Spirometry Obstructive, restrictive, and mixed patterns in 35 (62.50%),

9 (16.07%), and 12 (21.42%), respectively

PTB causes significant impairment of lung function,

predominantly airway obstruction due to lung destruction

and inammation.

Pefura-Yone et

al., 2014

(30)

Cameroon 177 Cured PTB Spirometry Distal airow obstruction (FEF

25-75%

< 65%) in 67 (62.9%);

and at least one chronic respiratory sign in 110 (62.1%)

FEF

25-75%

< 65% is a useful instrument to evaluate post-TB distal

airow obstruction

Ralph et al.,

2013

(31)

Papua New Guinea 200 PTB patients

vs. 40 healthy

subjects

Smear-positive

TB (direct sputum

examination)

Spirometry,

6MWT, and SGRQ

Mean pre-treatment FEV

1

% predicted (controls vs. PTB

patients) = 92 vs. 63 (p < 0.0001); 6MWD = 497 m vs. 408

m (p < 0.0001); SGRQ = 0 vs. 36.9 (p < 0.0001)

In PTB patients, post-treatment FEV

1

% = 71 (p < 0.0001

vs. controls); 6MWD = 470 m (p = 0.02); and SGRQ = 4.3

(p < 0.0001).

Early TB detection and treatment are key in minimizing

residual impairment.

Vecino et al.,

2011

(32)

USA 123 Culture-positive PTB Spirometry Spirometry at 20 weeks of treatment and at the end of

it; mean changes: FVC = −0.02 L (95% CI: −0.09 to 0.06 L);

FVC% predicted = −0.02% (95% CI: −2.17% to 2.12%); FEV

1

= 0 L (95% CI: −0.05 to 0.06L); FEV

1

% predicted = −0.11%

(95% CI: −1.82% to 1.60%)

Pulmonary impairment after PTB treatment was not

associated with duration of delay in TB diagnosis and

treatment and did not signicantly change during follow-up

376

J Bras Pneumol. 2016;42(5):374-385

Muñoz-Torrico M, Rendon A, Centis R, D’Ambrosio L, Fuentes Z, Torres-Duque C, et al.

Authors, year Study location

(name)

a

Participants

b

(n)

Cases investigated Investigations

performed

Major functional findings Conclusions

Lee et al.,

2011

(33)

South Korea

(KNHANES II study

2001)

c

3,687 Evidence of PTB on

CXR

CXR and

spirometry

Evidence of PTB on CXR is associated with airflow

obstruction (aOR = 2.56; 95% CI: 1.84- 3.56)

PTB is an independent risk factor for obstructive lung disease

in never-smokers.

Chung et al.,

2011

(34)

Taiwan 115 Culture-positive PTB Spirometry Nadir of pulmonary function occurs approximately 18

months after treatment completion; risk factors for

pulmonary function deterioration were positive sputum

smear microscopy, extensive pulmonary involvement,

prolonged anti-TB treatment, and reduced improvement

on CXR after treatment

In patients with signicant respiratory symptoms and multiple

risk factors, pulmonary function tests should be used to

monitor progression of functional impairment

Lam et al.,

2010

(35)

China (Guangzhou

Biobank Cohort

Study)

8,066 (73.6%

women and

26.4% men)

Evidence suggestive of

inactive PTB on CXR

CXR and

spirometry

Prevalence of prior TB was 24.2%; prior PTB is associated

with airow obstruction (aOR = 1.37; 95% CI: 1.13-1.67);

smoking did not modify this relationship

Prior TB is an independent risk factor for airow obstruction,

regardless of smoking status

Baig et al.,

2010

(36

Pakistan 92 History of PTB with

chronic exertional

dyspnea with or

without cough.

Evidence of inactive

PTB on CXR

Spirometry 26 (55.3%) with obstructive pattern [severe/stage III in 18

(69.2%); moderate/stage II in 6 (23.0%); mild/stage I in 2

(5.9%)]; 14 (29.7%) with restrictive pattern; and 7 (14.8%)

with mixed pattern

COPD can occur as one of the chronic complications of PTB

Pasipanodya

et al., 2007

(37)

USA 107 PTB patients

and 20 LTBI

patients

Culture-positive

PTB or PTB and

extrapulmonary TB

patients who had

completed at least 20

weeks of therapy

Spirometry PTB survivors are more likely to have abnormal spirometric

results than patients with LTBI (aOR = 5.4; 95% CI: 2.98-

9.68)

Pulmonary impairment after TB is associated with disability

worldwide and demands more aggressive prevention strategies

and post-treatment evaluation

Menezes et al.,

2007

(38)

Mexico, Venezuela,

Brazil, Uruguay,

Chile (PLATINO

study)

c

5,571 Self-reported history

of PTB

Spirometry Airow obstruction in 30.7% of the sample; history of PTB

is associated with airow obstruction (aOR = 2.33; 95%

CI: 1.50-3.62)

History of PTB is associated with airway obstruction

de la Mora

et al., 2015

(39)

Mexico 70 Cured PTB Spirometry and

CAT

Nonreversible chronic obstruction in 24 (34.3%): mean post-

bronchodilation FEV

1

= 1.32 ± 0.6 L and 57.30% ± 9.95% of

predicted; CAT score = 15.1 ± 10.4

Functional abnormalities are frequent in PTB patients

Di Naso et al.,

2011

(53)

Brazil 37 (25 DS-PTB vs.

12 MDR-PTB)

Cured PTB CXR, spirometry,

6MWT, and

pressure

manometry

Severe combined respiratory disorder was the more

prevalent in MDR-PTB patients (9/12); MDR-PTB group

(vs. DS-PTB) showed signicantly lower values in FVC%

of predicted (43.58 ± 16.03 vs. 72.06 ± 14.95); FEV

1

% of

predicted (33.08 ± 15.64 vs. 66.13 ± 19.87); MIP (49.58 ±

12.55 cmH

2

O vs. 68.40 ± 22.78 cmH

2

O); MEP (59.08 ± 12.23

cmH

2

O vs. 87.20 ± 27.30 cmH

2

O); and 6MWD (334.75 ±

104.07 m vs. 484.21 ± 74.01 m)

Patients with MDR-PTB who have undergone multiple

treatments have more severe respiratory and functional

impairment than do patients who have had just a single

treatment

de Vallerière

et al., 2004

(54)

South Africa 33 MDR-PTB Cured PTB CXR and

spirometry

Cavitation was present in more than half of the patients. 31

(94%) with abnormal lung function tests: restrictive pattern

in 14 (42%); combined pattern in 13 (39%); obstructive

pattern in 4 (12%); and normal spirometric results in 2 (6%)

Residual lung damage in MDR-PTB patients who completed

treatment is common and extensive

PTB: pulmonary tuberculosis; CXR: chest X-ray; CAO: chronic airway obstruction; TB: tuberculosis; aOR: adjusted odds ratio; 6MWT: six-minute walk test; SGRQ: Saint George’s Respiratory Questionnaire; 6MWD:

six-minute walk distance; LTBI: latent TB infection; CAT: COPD assessment test; DS-PTB: drug-susceptible PTB; and MDR-PTB: multidrug-resistant PTB.

a

BOLD: Burden of Obstructive lung disease; KNHANES:

Korean National Health and Nutrition Examination Surveys; and PLATINO: Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar.

b

All studies included both men and women.

c

Population-based studies.

Table 1. Continued...

377

J Bras Pneumol. 2016;42(5):374-385

Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis?

that exercise is an important element in the care of

patients with lung and heart diseases, especially in

tuberculosis.

(17)

In a recent American Thoracic Society (ATS)/European

Respiratory Society (ERS) statement, as well as in a

guideline from South Africa for the management of

COPD, tuberculosis is clearly among the diseases that

require the use of PR.

(18,19)

“DESTROYED LUNG”

Late diagnosis is often responsible for extensive

bilateral lesions, usually due to bronchiectasis, scarring,

parenchymal deformation, lung volume loss, and

pleural thickening, which might develop to the so-called

“destroyed lung” (Figure 1).

(20)

Two studies described the effect of “destroyed

lung” on the pulmonary function of patients treated

for pulmonary tuberculosis, both carried out in South

Korea.

(21,22)

Rhee et al.

(21)

studied 595 tuberculosis

patients from 21 hospitals between 2005 and 2011.

The mean extension of the lesions was 2.59 ± 0.05

lobes, and pleural thickening was observed in 54.1%

of the patients. Various lung function parameters were

reduced (mean values): FVC = 2.06 ± 0.03 L (61.26%

± 0.79% of predicted); FEV

1

= 1.16 ± 0.02 L (49.05%

± 0.84% of predicted); FEV

1

/FVC ratio = 58.0% ±

0.70%; bronchodilator response = 5.70% ± 0.34%;

and number of exacerbations/year = 0.40 ± 0.04.

The number of lobes involved signicantly correlated

with FVC, FEV

1

, and the number of exacerbations/

year. The use of long-acting muscarinic antagonists

or long-acting β

2

agonists plus inhaled corticosteroids

achieved bronchodilator effects. Initial FEV

1

% and

the number of exacerbations during follow-up were

independent factors affecting FEV

1

deterioration in the

multivariate analysis.

Lee et al.

(22)

investigated lung function and

post-bronchodilator response in 21 patients with

“destroyed lung”-related chronic airow obstruction

against a cohort of COPD patients matched by sex,

age, and pulmonary function parameters. The mean

FVC values (both in L and in % of predicted) of the

patients with “destroyed lung” were signicantly lower

than those of the COPD patients (2.14 ± 0.73 L vs.

2.60 ± 0.69 L and 57.9% ± 14.8% vs. 70.0 ± 14.8%,

respectively). The tuberculosis patients presented with

signicantly lower FVC and post-bronchodilator FEV

1

than did the COPD patients. In addition, among the

tuberculosis patients, those with wheezing symptoms

showed significantly lower FEF

25-75%

and higher

airway resistance than did those without wheezing.

Tuberculosis patients with wheezing responded better

to the bronchodilator than did those without it. The

authors concluded that bronchodilator therapy could

be useful in those patients.

In Mexico, 127 cured tuberculosis patients underwent

spirometry and CXR; 123 (96.85%) exhibited some

degree of radiographic abnormalities.

(23)

The extent

of lung damage was measured by dividing the lung

parenchyma into four quadrants and scoring it from 0

to 5; the mean number of radiographic abnormalities

was 6.45 ± 4.14. In that sample, 30 patients (24%)

showed an obstructive spirometric pattern, and 22

(17%), a restrictive pattern; only 15 (12%) had a

positive bronchodilator test, and 21 (17%) had an SpO

2

< 90%. The adjusted multilinear regression model

showed that the degree of radiographic abnormalities

was independently associated with a decrease in the

absolute values of FVC (0.07 L; 95% CI: −0.01 to

−0.04) and FEV

1

(0.07 L; 95% CI: −0.10 to −0.05;

p < 0.001); as well as in their % of predicted values

(FVC = 2.48%; 95% CI: −3.45 to −1.50; and FEV

1

= 2.92%; 95% CI: −3.87 to −1.97). That study

showed that spirometric values were associated with

the degree of radiographic abnormalities assessed by

a simple scoring method.

FUNCTIONAL EVALUATION OF SEQUELAE

Several studies investigated the mechanical lung

function in tuberculosis patients (Figure 2).

Already in 1961, Hallet and Martin

(24)

described the

diffuse obstructive pulmonary syndrome (measured

via the maximal expiratory ow rate) in 34% of 710

tuberculosis patients admitted to a sanatorium during

a one-year period. The factors signicantly associated

with the incidence of that syndrome were age, severity

of tuberculosis, and some comorbidities (bronchial

asthma, pulmonary malignancy, frequent and protracted

chest colds, and silicosis). The authors concluded

that the measurement of maximal expiratory ow

rate is a useful tool in determining diffuse obstructive

pulmonary disease.

Willcox and Ferguson

(25)

investigated 71 patients

previously treated for tuberculosis up to 16 years prior.

Evidence of airway obstruction was found in 48 (68%)

of the patients. An inverse relationship between the

extent of the disease on the original CXRs and FEV

1

Figure 1. Chest X-ray of a 39-year-old male patient with

a history of pan-susceptible tuberculosis treated for six

months in 2007. The patient was considered cured. Later

in time, he reported a six-month history of cough, mild

dyspnea, but no fever. Tuberculosis relapse was ruled out;

sputum smear microscopy and culture were negative. The

image shows a giant cavity in the right upper lobe and

some brotic changes.

378

J Bras Pneumol. 2016;42(5):374-385

Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis

Citations

MDR/XDR-TB management of patients and contacts: challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network.

Surveillance of adverse events in the treatment of drug-resistant tuberculosis: first global report

Post-tuberculosis lung health: perspectives from the First International Symposium.

International research and guidelines on post-tuberculosis chronic lung disorders: a systematic scoping review.

A pre–post intervention study of pulmonary rehabilitation for adults with post-tuberculosis lung disease in Uganda

References

An official American thoracic society/European respiratory society statement: Key concepts and advances in pulmonary rehabilitation

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

Towards tuberculosis elimination: an action framework for low-incidence countries

World Health Organization treatment guidelines for drug-resistant tuberculosis, 2016 update.

Chronic pulmonary function impairment caused by initial and recurrent pulmonary tuberculosis following treatment

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