Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart
  • Log out

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • ERS Guidelines
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • Peer reviewer login
  • Alerts
  • Subscriptions

Determinants of success

R. Garrod, M. Malerba, E. Crisafulli
European Respiratory Journal 2011 38: 1215-1218; DOI: 10.1183/09031936.00088611
R. Garrod
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
M. Malerba
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
E. Crisafulli
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: crisafulli.ernesto@villapineta.it
  • Article
  • Info & Metrics
  • PDF
Loading

Abstract

In chronic obstructive pulmonary disease (COPD) patients, pulmonary rehabilitation is a nonpharmacological intervention aimed at improving physical exercise tolerance, dyspnoea and perceived quality of life. However, identifying predictors of clinical response and which patients achieve benefit remains a difficult question to answer with no conclusive data available.

Baseline characteristics of COPD patients, such as degree of breathlessness, body weight and arterial partial pressure of oxygen, generally appear to be too direct to have a correlation with improvement of post-rehabilitation outcomes. Furthermore, some additional benefits of patients treated with rehabilitation are simply not detected by usual measures (social interaction, sleep quality and confidence).

Although there are some data suggesting that some medical conditions frequently associated with COPD (osteoporosis, metabolic syndrome and heart diseases) may negatively influence rehabilitation outcomes, at present the evidence is contradictory.

  • Attendance
  • chronic obstructive pulmonary disease
  • comorbidities
  • effectiveness
  • minimum clinically important difference
  • predictors
  • pulmonary rehabilitation

Pulmonary rehabilitation is a nonpharmacological intervention, which is effective for chronic obstructive pulmonary disease (COPD) patients who complete, take part and engage. The treatment effect is large and benefits on exercise capacity, dyspnoea and quality of life consistently exceed the minimum clinically important difference (MCID) for these outcomes [1, 2]. However, determining who benefits most from pulmonary rehabilitation remains a difficult question.

In one clinical analysis of 91 subjects undertaking pulmonary rehabilitation, an evaluation of response was made after categorising response into dichotomous or composite measures of health status and/or exercise tolerance [3]. In this study, 37% of patients achieved benefits in both health status and exercise tolerance whereas 27% were nonresponders for both: 17% and 14%, respectively, showed improvements in health status or exercise tolerance only. Identifying predictors of response was difficult and no conclusive data were available. Although, in this study, patients with baseline breathlessness at Medical Research Council (MRC) level 5 (housebound by breathlessness) showed a smaller magnitude of improvement, in combination with other variables, this was not a significant predictor.

In another study examining response to pulmonary rehabilitation, the authors identified that patients who performed well with rehabilitation tended to be those who had more peripheral muscle weakness and less ventilatory limitation at the start of the programme compared with those who were stronger but more ventilatory impaired [4]. This compelling data makes clinical sense but is limited in application to rehabilitation services, particularly in the UK, where muscle strength is not routinely measured. Furthermore, these findings accounted for only a small percentage of the variance in response in patients with COPD.

In a more recent observational study aimed at defining the clinical predictors of pulmonary rehabilitation efficacy, comprehensive data was available on lung function parameters in 60 severe COPD patients and included in the regression analyses [5]. In this analysis patients were categorised according to the following baseline variables: pulmonary hyperinflation, body mass index (BMI), arterial oxygen tension (Pa,O2) and severity of airflow obstruction. Whilst these baseline variables were unable to account for differences in change in quality of life after rehabilitation, there was evidence that patients with a BMI >25 kg·m−2 and greater initial hypoxaemia (Pa,O2 <60 mmHg) did better with respect to changes in 6-min walking distance (6MWD). This is an interesting and perhaps unexpected finding, although it does support earlier data, which suggest that hypoxic patients do well even when trained without additional oxygen [6]. However, confidence intervals for these findings were wide-ranging, reflecting the relatively small sample size. Furthermore, the relationship between baseline arterial oxygen and change in 6MWD, considered as a continuous, as opposed to dichotomised, variable, was nonsignificant and only suggestive of a relationship for BMI. In other studies, the physiological response of 6MWD has been shown to be similar between obese and nonobese COPD patients [7] and in one head-to-head comparison, obese patients performed as well with rehabilitation as nonobese patients [8].

ATTENDANCE

One important determinant of success may be attendance of rehabilitation sessions. In one study offering different frequencies of supervised sessions (once weekly versus twice weekly), attendance between the two groups was not different, although the once weekly groups attended for a longer period of time [9]. Outcomes between the two groups were similar, although health-related quality of life changes were smaller in the once weekly group. However, with a very small sample size, caution is required.

Many authors have considered the causes of nonattendance and drop-out in more detail; in the study by Fischer et al. [10], 50 (23%) out of 217 patients did not complete the course. For ∼50% of these, drop-out was explained by the illness itself, exacerbations, deterioration in symptoms or comorbidities. Those who dropped out for medical reasons were no different to those who dropped out for other reasons (e.g. limitations in social activities) [10]. In this study, drop-out was unexplained by any measured clinical or psychosocial variables; however, depression was not measured, which has previously been shown to be a predictor of drop-out [2].

When looking at causes of nonattendance during rehabilitation, Fischer et al. [10] found that ∼27% of causes were due to COPD or other comorbidities and 31% of absenteeism was unexplained. Using multiple regression techniques to compare high and poor attendance records, the authors found a combination of low fat-free mass and poor sense of control predicted poor attendance. Although continued smoking was higher in those with poor attendance, this was not significant in the regression analysis. Again, it should be highlighted that with relatively low-frequency “events”, for example, poor attendance or drop-out, larger sample sizes are required to avoid spurious results. To what extent low fat-free mass reflects severity of illness and, as such, impacts on attendance remains unclear. Interestingly, distance and travel time to the sites did not appear to influence attendance. With average travel times of 20 min for both high and low attendees, this may be significantly greater in other countries and perhaps further complicated by parking restrictions, availability of public transport and hospital-provided transport.

PATIENT'S COMPLEXITY

Advanced COPD is frequently seen in association with other medical conditions, such as systemic hypertension, diabetes, coronary artery disease and heart failure. These comorbidities share pathophysiological mechanisms and influence patients’ health [11, 12]. Indeed, somatic chronic comorbidities appear to have greater negative influence on the individual's decline in physical functions than expected [13]. In elderly people [14], comorbidities may negatively impact on the rehabilitation of patients, leading to smaller gains [15, 16].

This aspect has been further investigated in COPD patients. In a single-centre, retrospective analysis using a large sample size (n=2,962; mean age 71 yrs), the impact of single or aggregated comorbidities on outcomes associated with pulmonary rehabilitation was explored [17].

Authors have shown that some comorbidities can significantly influence discharge outcomes in patients who underwent a standard programme. In particular, the proportion of patients with a pre-defined improvement greater than the MCID in perceived breathlessness (-1 point on the modified MRC scale) [18, 19] and health-related quality of life (-4 points on the St George's Respiratory Questionnaire (SGRQ)) [20, 21] did not differ across categories of COPD patients with no, one or at least two comorbidities. In addition, the number and percentage of patients who clinically improved in exercise performance (54 m at 6MWD) [22] was not different according to the same comorbidity categories [17] (62, 59 and 62%, respectively). In a multiple logistic regression model, individuals' self-reported comorbidity score, as assessed by the index of Charlson et al. [23], and the presence of metabolic syndrome (systemic hypertension, diabetes and dyslipidaemia) were inversely related to improvement in 6MWD (OR 0.72 and 0.57, respectively) [17]. Moreover, heart diseases such as chronic heart failure and/or coronary heart disease directly and indirectly predicted the improvement in exercise tolerance (OR 2.36) and perceived quality of life (OR 0.67) [17].

Vagaggini et al. [5] showed similar results in COPD outpatients with comorbidities. Specifically, these authors found a significant improvement in 6MWD and SGRQ at the end of 8 weeks of physical training in all patients except for those with associated cardiovascular disease, even if stable. However, in contrast to the findings of the previous paper, the presence of cardiovascular comorbidities (n=16 patients, 26%) was not a significant predictor of poor response to pulmonary rehabilitation, although comorbidities did reduce the likelihood of reaching the MCID threshold for both 6MWD and SGRQ (OR 0.93 and 0.43, respectively).

More recently, an Italian group of researchers examined the potential effect of comorbidities on the rehabilitation outcome with a prospective trial at four Italian hospitals in 316 selected moderate and severe COPD outpatients [24]. There was no association between number and type of comorbidities (even if alone or in combination) and pulmonary rehabilitation effectiveness. Only the presence of osteoporosis was inversely related as a negative predictor in walking performance as assessed by 6MWD (OR 0.28, 95% CI 0.11–0.70). This was probably linked to specific factors such as bone frailty, muscle weakness and/or steroid-related myopathy, which typically occur in COPD patients.

This aspect of frailty related to osteoporosis and bone diseases has been confirmed in a study on >700 elderly patients admitted for physical rehabilitation after stroke and who had pre-existing Parkinson's disease or osteoarthritis [25]. In that study, which aimed at considering the independent role of comorbidities on the functional outcomes of balance and gait, the authors showed that the main determinants of poor physical recovery were characterised by a combination of disabling comorbidities, including osteoporosis and arthrosis, rather than the effect of each chronic disease, independent of age, cognitive status or functional status at admission.

With respect to the complexity of COPD, two other factors may also have a potential role on pulmonary rehabilitation efficacy. Indeed, chronic respiratory failure (CRF) and obesity may substantially compromise pulmonary function and the health status of COPD patients, thus, increasing the risk of death for all causes [26–29].

To examine the effectiveness of pulmonary rehabilitation in patients with CRF, an Italian observational, multicentre trial considered 327 severe and disabled COPD patients (forced expiratory volume in 1 s 37% predicted and baseline 6MWD of 283 m) [30]. After a standard programme, improvements in exercise tolerance and dyspnoea perception were similar when comparing those with CRF and those without (48 and 47 m in 6MWD and -0.85 and -0.73 points on the MRC score, respectively). A recent publication in COPD patients further confirmed these findings as there was no correlation between the presence of CRF and the success rate of rehabilitation [31].

Finally, the impact of obesity on rehabilitation outcomes in COPD patients has been evaluated in a retrospective study from a single centre [8]. The authors found that obesity did not adversely affect rehabilitation success: baseline exercise performance (6MWD) was similar between obese (BMI >30 kg·m−2) and nonobese COPD patients (203 versus 269 m walked) and both groups improved following pulmonary rehabilitation (47 and 52 m, respectively). A very recent prospective trial on 261 patients with severe COPD included being overweight as a potential factor of response to pulmonary rehabilitation. Although obese COPD patients had reduced walking capacity at baseline compared with nonobese patients, all participants, those of normal weight and those who were overweight and obese, improved walking capacity to a similar extent after pulmonary rehabilitation [32]. However, the percentage of subjects reaching the clinically significant change of 6MWD after rehabilitation was lower in obese (15%) compared with normal weight (24%) or overweight (18%) subjects. Interestingly, this was not the case for perceived quality of life. In a regression analysis, the changes in 6MWD distance and SGRQ scores were not statistically associated with the patients' body weight.

In conclusion, baseline characteristics appear too direct, in general, to identify the reasons for one person’s success and another’s failure in a pulmonary rehabilitation programme. Furthermore, there may be additional benefits to rehabilitation that are simply not detected by usual measures, for instance, improved social interaction, better sleep quality and greater confidence. Although there are some data suggesting that osteoporosis, metabolic syndrome and Charlson index may negatively impact on the outcome of pulmonary rehabilitation, the evidence is, at present, contradictory. Indeed, overweight patients and those with CRF appear to do as well as those without. As exercise is beneficial for most conditions, patients with COPD and comorbidities should be encouraged to take part in rehabilitation where able.

Acknowledgments

We are very grateful to E.M. Clini (Dept of Oncology, Haematology and Respiratory Diseases, University of Modena-Reggio Emilia, Italy) for his manuscript revision.

Footnotes

  • Previous articles in this series: No. 1: Burtin C, Decramer M, Gosselink R, et al. Rehabilitation and acute exacerbations. Eur Respir J 2011; 38: 702–712. No. 2: Vogiatzis I. Strategies of muscle training in very severe COPD patients. Eur Respir J 2011; 38: 971–975.

  • Statement of Interest

    None declared.

  • Received May 25, 2011.
  • Accepted June 1, 2011.
  • ©ERS 2011

REFERENCES

  1. ↵
    1. Nici L,
    2. Donner C,
    3. Wouters E,
    4. et al
    . American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390–1413.
    OpenUrlCrossRefPubMedWeb of Science
  2. ↵
    1. Lacasse Y,
    2. Martin S,
    3. Lasserson TJ,
    4. et al
    . Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. A Cochrane systematic review. Eura Medicophys 2007; 43: 475–485.
    OpenUrlPubMed
  3. ↵
    1. Garrod R,
    2. Marshall J,
    3. Barley E,
    4. et al
    . Predictors of success and failure in pulmonary rehabilitation. Eur Respir J 2006; 27: 788–794.
    OpenUrlAbstract/FREE Full Text
  4. ↵
    1. Troosters T,
    2. Gosselink R,
    3. Decramer M
    . Exercise training in COPD: how to distinguish responders from nonresponders. J Cardiopulm Rehabil 2001; 21: 10–17.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Vagaggini B,
    2. Costa F,
    3. Antonelli S,
    4. et al
    . Clinical predictors of the efficacy of a pulmonary rehabilitation programme in patients with COPD. Respir Med 2009; 103: 1224–1230.
    OpenUrlCrossRefPubMedWeb of Science
  6. ↵
    1. Garrod R,
    2. Paul EA,
    3. Wedzicha JA
    . Supplemental oxygen during pulmonary rehabilitation in patients with COPD with exercise hypoxaemia. Thorax 2000; 55: 539–543.
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Bautista J,
    2. Ehsan M,
    3. Normandin E,
    4. et al
    . Physiologic responses during the six minute walk test in obese and non-obese COPD patients. Respir Med 2011; 105: 1189–1194.
    OpenUrlCrossRefPubMed
  8. ↵
    1. Ramachandran K,
    2. McCusker C,
    3. Connors M,
    4. et al
    . The influence of obesity on pulmonary rehabilitation outcomes in patients with COPD. Chron Respir Dis 2008; 5: 205–209.
    OpenUrlAbstract/FREE Full Text
  9. ↵
    1. Liddell F,
    2. Webber J
    . Pulmonary rehabilitation for chronic obstructive pulmonary disease: a pilot study evaluating a once-weekly versus twice-weekly supervised programme. Physiotherapy 2010; 96: 68–74.
    OpenUrlCrossRefPubMedWeb of Science
  10. ↵
    1. Fischer MJ,
    2. Scharloo M,
    3. Abbink JJ,
    4. et al
    . Drop-out and attendance in pulmonary rehabilitation: the role of clinical and psychosocial variables. Respir Med 2009; 103: 1564–1571.
    OpenUrlCrossRefPubMedWeb of Science
  11. ↵
    1. Soriano JB,
    2. Visick GT,
    3. Muellerova H,
    4. et al
    . Patterns of comorbidities in newly diagnosed COPD and asthma in primary care. Chest 2005; 128: 2099–2107.
    OpenUrlCrossRefPubMedWeb of Science
  12. ↵
    1. Sevenoaks MJ,
    2. Stockley RA
    . Chronic obstructive pulmonary disease, inflammation and co-morbidity – a common inflammatory phenotype?. Respir Res 2006; 7: 70.
    OpenUrlCrossRefPubMed
  13. ↵
    1. Kriegsman DM,
    2. Deeg DJ,
    3. Stalman WA
    . Comorbidity of somatic chronic diseases and decline in physical functioning: the Longitudinal Aging Study Amsterdam. Clin Epidemiol 2004; 57: 55–65.
    OpenUrlCrossRefPubMedWeb of Science
  14. ↵
    1. Guralnik JM,
    2. LaCroix AZ,
    3. Abbott RD,
    4. et al
    . Maintaining mobility in late life. I. Demographic characteristics and chronic conditions. Am J Epidemiol 1993; 137: 845–857.
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Bellelli G,
    2. Guerini F,
    3. Bianchetti A,
    4. et al
    . Medical comorbidity and complexity of the rehabilitative procedures for older patients with functional impairments. J Am Geriatr Soc 2002; 50: 2095–2096.
    OpenUrlCrossRefPubMedWeb of Science
  16. ↵
    1. Patrick L,
    2. Knoefel F,
    3. Gaskowski P,
    4. et al
    . Medical comorbidity and rehabilitation efficiency in geriatric inpatients. J Am Geriatr Soc 2001; 49: 1471–1477.
    OpenUrlCrossRefPubMedWeb of Science
  17. ↵
    1. Crisafulli E,
    2. Costi S,
    3. Luppi F,
    4. et al
    . Role of comorbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation. Thorax 2008; 63: 487–492.
    OpenUrlAbstract/FREE Full Text
  18. ↵
    1. Fletcher CM
    . Standardised questionnaire on respiratory symptoms: a statement prepared and approved by the MRC Committee on the aetiology of chronic bronchitis (MRC breathlessness score). Br Med J 1960; 2: 1665.
    OpenUrlFREE Full Text
  19. ↵
    1. De Torres JP,
    2. Pinto-Plata V,
    3. Ingenito E,
    4. et al
    . Power of outcome measurements to detect clinically significant changes in pulmonary rehabilitation of patients with COPD. Chest 2002; 121: 1092–1098.
    OpenUrlCrossRefPubMedWeb of Science
  20. ↵
    1. Jones PW
    . Health status measurement in chronic obstructive pulmonary disease. Thorax 2001; 56: 880–887.
    OpenUrlAbstract/FREE Full Text
  21. ↵
    1. Carone M,
    2. Bertolotti G,
    3. Anchisi F,
    4. et al
    . The St. George's Respiratory Questionnaire (SGRQ): Italian version. Rassegna Patol App Respir 1999; 14: 31–37.
    OpenUrl
  22. ↵
    1. Redelmeier DA,
    2. Bayoumi AM,
    3. Goldstein RS,
    4. et al
    . Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med 1997; 155: 1278–1282.
    OpenUrlCrossRefPubMedWeb of Science
  23. ↵
    1. Charlson ME,
    2. Pompei P,
    3. Ales KL,
    4. et al
    . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383.
    OpenUrlCrossRefPubMedWeb of Science
  24. ↵
    1. Crisafulli E,
    2. Gorgone P,
    3. Vagaggini B,
    4. et al
    . Efficacy of standard rehabilitation in COPD outpatients with comorbidities. Eur Respir J 2010; 36: 1042–1048.
    OpenUrlAbstract/FREE Full Text
  25. ↵
    1. De Fazio I,
    2. Franzoni S,
    3. Frisoni GB,
    4. et al
    . Predictive role of single diseases and their combination on recovery of balance and gait in disabled elderly patients. J Am Med Dir Assoc 2006; 7: 208–211.
    OpenUrlCrossRefPubMedWeb of Science
  26. ↵
    1. Ekström MP,
    2. Wagner P,
    3. Ström KE
    . Trends in cause-specific mortality in oxygen-dependent chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2011; 183: 1032–1036.
    OpenUrlCrossRefPubMedWeb of Science
    1. Landbo C,
    2. Prescott E,
    3. Lange P,
    4. et al
    . Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160: 1856–1861.
    OpenUrlCrossRefPubMedWeb of Science
    1. Celli BR,
    2. Cote CG,
    3. Marin JM,
    4. et al
    . The body-mass index, airflow obstruction, dyspnoea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004; 350: 1005–1012.
    OpenUrlCrossRefPubMedWeb of Science
  27. ↵
    1. Yach D,
    2. Hawkes C,
    3. Gould CL,
    4. et al
    . The global burden of chronic diseases. Overcoming impediments to prevention and control. JAMA 2004; 291: 2616–2622.
    OpenUrlCrossRefPubMedWeb of Science
  28. ↵
    1. Carone M,
    2. Patessio A,
    3. Ambrosino N,
    4. et al
    . Efficacy of pulmonary rehabilitation in chronic respiratory failure (CRF) due to chronic obstructive pulmonary disease (COPD): the Maugeri Study. Respir Med 2007; 101: 2447–2453.
    OpenUrlCrossRefPubMedWeb of Science
  29. ↵
    1. Scott AS,
    2. Baltzan MA,
    3. Fox J,
    4. et al
    . Success in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Can Respir J 2010; 17: 219–223.
    OpenUrlPubMed
  30. ↵
    1. Sava F,
    2. Laviolette L,
    3. Bernard S,
    4. et al
    . The impact of obesity on walking and cycling performance and response to pulmonary rehabilitation in COPD. BMC Pulm Med 2010; 10: 55.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top
View this article with LENS
Vol 38 Issue 5 Table of Contents
European Respiratory Journal: 38 (5)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Determinants of success
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Determinants of success
R. Garrod, M. Malerba, E. Crisafulli
European Respiratory Journal Nov 2011, 38 (5) 1215-1218; DOI: 10.1183/09031936.00088611

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Determinants of success
R. Garrod, M. Malerba, E. Crisafulli
European Respiratory Journal Nov 2011, 38 (5) 1215-1218; DOI: 10.1183/09031936.00088611
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • ATTENDANCE
    • PATIENT'S COMPLEXITY
    • Acknowledgments
    • Footnotes
    • REFERENCES
  • Info & Metrics
  • PDF

Subjects

  • COPD and smoking
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Asthma remission: what is it and how can it be achieved?
  • Asthma management in low and middle income countries
  • Calcilytics for the management of asthma
Show more Series

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2023 by the European Respiratory Society