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• W2146985504 abstract "Background: Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation.Methods: The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system.Results: The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD.Conclusions: There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need. Background: Pulmonary rehabilitation has become a standard of care for patients with chronic lung diseases. This document provides a systematic, evidence-based review of the pulmonary rehabilitation literature that updates the 1997 guidelines published by the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation. Methods: The guideline panel reviewed evidence tables, which were prepared by the ACCP Clinical Research Analyst, that were based on a systematic review of published literature from 1996 to 2004. This guideline updates the previous recommendations and also examines new areas of research relevant to pulmonary rehabilitation. Recommendations were developed by consensus and rated according to the ACCP guideline grading system. Results: The new evidence strengthens the previous recommendations supporting the benefits of lower and upper extremity exercise training and improvements in dyspnea and health-related quality-of-life outcomes of pulmonary rehabilitation. Additional evidence supports improvements in health-care utilization and psychosocial outcomes. There are few additional data about survival. Some new evidence indicates that longer term rehabilitation, maintenance strategies following rehabilitation, and the incorporation of education and strength training in pulmonary rehabilitation are beneficial. Current evidence does not support the routine use of inspiratory muscle training, anabolic drugs, or nutritional supplementation in pulmonary rehabilitation. Evidence does support the use of supplemental oxygen therapy for patients with severe hypoxemia at rest or with exercise. Noninvasive ventilation may be helpful for selected patients with advanced COPD. Finally, pulmonary rehabilitation appears to benefit patients with chronic lung diseases other than COPD. Conclusions: There is substantial new evidence that pulmonary rehabilitation is beneficial for patients with COPD and other chronic lung diseases. Several areas of research provide opportunities for future research that can advance the field and make rehabilitative treatment available to many more eligible patients in need. American Association of Cardiovascular and Pulmonary Rehabilitation American College of Chest Physicians activity of daily living Chronic Respiratory Disease Questionnaire distractive auditory stimuli dual-energy x-ray absoptiometry education and stress management heart rate health-related quality of life inspiratory muscle training Medical Research Council National Emphysema Treatment Trial noninvasive positive-pressure ventilation proportional assist ventilation maximal inspiratory pressure randomized controlled trial arterial oxygen saturation transcutaneous electrical stimulation of the peripheral muscles minute ventilation oxygen uptake Pulmonary diseases are increasingly important causes of morbidity and mortality in the modern world. The COPDs are the most common chronic lung diseases, and are a major cause of lung-related death and disability.1Higgins ITT Epidemiology of bronchitis and emphysema..in: Fishman AP Pulmonary diseases and disorders. McGraw-Hill Book Co, New York, NY1988: 1237-1246Google Scholar Pulmonary rehabilitation has emerged as a recommended standard of care for patients with chronic lung disease based on a growing body of scientific evidence. A previous set2American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation..Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines; ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Chest. 1997; 112: 1363-1396Google Scholar,3ACCP-AACVPR Pulmonary Rehabilitation Guidelines Panel..Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. J Cardiopulm Rehabil. 1997; 17: 371-405Google Scholar of evidence-based guidelines was published in 1997 as a joint effort of the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Since then, the published literature in pulmonary rehabilitation has increased substantially, and other organizations have published important statements about pulmonary rehabilitation (eg, the American Thoracic Society and the European Respiratory Society4American Thoracic Society, European Respiratory Society..ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006; 173: 1390-1413Crossref Scopus (1084) Google Scholar). The purpose of this document is to update the previous ACCP/AACVPR document with a systematic, evidence-based review of the literature published since then.EPIDEMIOLOGY OF COPOIn the United States, COPD accounted for 119,054 deaths in 2000, ranking as the fourth leading cause of death and the only major disease among the top 10 in which mortality continues to increase.5Mannino DM Homa DM Akinbami LJ et al.Chronic obstructive pulmonary disease surveillance: United States, 1971-2000..MMWR Morb Mortal Wkly Rep. 2002; 51: 1-16Google Scholar, 6Minino AM Smith BL Deaths: preliminary data for 2000..Natl Vital Stat Rep. 2001; 49: 1-40Google Scholar, 7Mannino DM Gagnon R Petty TL et al.Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994..Arch Intern Med. 2000; 160: 1683-1689Crossref PubMed Google Scholar, 8Petty TL Scope of the COPD problem in North America: early studies of prevalence and NHANES III data; basis for early identification and intervention..Chest. 2000; 117: 326S-331SAbstract Full Text Full Text PDF PubMed Google Scholar In persons 55 to 74 years of age, COPD ranks third in men and fourth in women as cause of death.9American Cancer Society..Cancer statistics, 1989. CA Cancer J Clin. 1989; 39: 6-11Google Scholar However, mortality data underestimate the impact of COPD because it is more likely to be listed as a contributory cause of death rather than the underlying cause of death, and it is often not listed at all.10Pauwels RA Buist AS Calverley PM et al.Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary..Am J Respir Crit Care Med. 2001; 163: 1256-1276Crossref PubMed Google Scholar,11Sherrill DL Lebowitz MD Burrows B Epidemiology of chronic obstructive pulmonary disease..Clin Chest Med. 1990; 11: 375-387PubMed Google Scholar Death rates from COPD have continued to increase more in women than in men.5Mannino DM Homa DM Akinbami LJ et al.Chronic obstructive pulmonary disease surveillance: United States, 1971-2000..MMWR Morb Mortal Wkly Rep. 2002; 51: 1-16Google Scholar Between 1980 and 2000, death rates for COPD increased 282% for women compared to only 13% for men. Also, in 2000, for the first time, the number of women dying from COPD exceeded the number of men.5Mannino DM Homa DM Akinbami LJ et al.Chronic obstructive pulmonary disease surveillance: United States, 1971-2000..MMWR Morb Mortal Wkly Rep. 2002; 51: 1-16Google ScholarMorbidity from COPD is also substantial.5Mannino DM Homa DM Akinbami LJ et al.Chronic obstructive pulmonary disease surveillance: United States, 1971-2000..MMWR Morb Mortal Wkly Rep. 2002; 51: 1-16Google Scholar,12Higgins MW Thom TJ Incidence, prevalence and mortality: intra- and intercountry differences..in: Hensley MJ Saunders NA Clinical epidemiology of chronic obstructive pulmonary disease. Marcel Dekker, New York, NY1989: 23-43Google Scholar COPD develops insidiously over decades and because of the large reserve in lung function there is a long preclinical period. Affected individuals have few symptoms and are undiagnosed until a relatively advanced stage of disease. In a population survey in Tucson, AZ, Burrows13Burrows B Epidemiologic evidence for different types of chronic airflow obstruction..Am Rev Respir Dis. 1991; 143: 1452-1455Crossref PubMed Google Scholar reported that only 34% of persons with COPD had ever consulted a physician, 36% denied having any respiratory symptoms, and 30% denied dyspnea on exertion, which is the primary symptom. National Health and Nutrition Examination Study III data estimate that 24 million US adults have impaired lung function, while only 10 million report a physician diagnosis of COPD.5Mannino DM Homa DM Akinbami LJ et al.Chronic obstructive pulmonary disease surveillance: United States, 1971-2000..MMWR Morb Mortal Wkly Rep. 2002; 51: 1-16Google Scholar There are approximately 14 million cases of chronic bronchitis reported each year, and 2 million cases of emphysema.14American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma..Am Rev Respir Dis. 1995; 152: S78-S121Google Scholar The National Center for Health Statistics for 1996 reported prevalence rates of chronic bronchitis and emphysema in older adults (eg, persons ge; 65 years of age) of 82 per 1,000 men and 106 per 1,000 women.15Adams PF Hendershot GE Marano MA Current estimates from the National Health Interview Survey, 1996..Vital Health Stat. 1999; 10: 82-92Google Scholar In 2000, COPD was responsible for 8 million physician office visits, 1.5 million emergency department visits, and 726,000 hospitalizations.5Mannino DM Homa DM Akinbami LJ et al.Chronic obstructive pulmonary disease surveillance: United States, 1971-2000..MMWR Morb Mortal Wkly Rep. 2002; 51: 1-16Google Scholar COPD accounts for > 5% of physician office visits and 13% of hospitalizations.16Feinleib M Rosenberg HM Collins JG et al.Trends in COPD morbidity and mortality in the United States..Am Rev Respir Dis. 1989; 140: S9-S18Crossref PubMed Google Scholar National Health and Nutrition Examination Study III data from 1988 to 1994 indicated an overall prevalence of COPD of 8.6% among 12,436 adults (average age for entire cohort, 37.9 years).17Sin DD Stafinski T Ng YC et al.The impact of chronic obstructive pulmonary disease on work loss in the United States..Am J Respir Crit Care Med. 2002; 165: 704-707Crossref PubMed Google Scholar In the United States, COPD is second only to coronary heart disease as a reason for Social Security disability payments.Worldwide, the burden of COPD is projected to increase substantially, paralleling the rise in tobacco use, particularly in developing countries. An analysis by the World Bank and World Health Organization ranked COPD 12th in 1990 in disease burden, as reflected in disability-adjusted years of life lost.10Pauwels RA Buist AS Calverley PM et al.Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary..Am J Respir Crit Care Med. 2001; 163: 1256-1276Crossref PubMed Google ScholarSEVERITY OF COPDFor consistency throughout the document, the panel used the description of severity of COPD as recommended by the Global Initiative for Chronic Obstructive Lung Disease18Global Initiative for Chronic Obstructive Lung Disease. Workshop report: global strategy for diagnosis, management, and prevention of COPD; updated 2005. Available at: http://goldcopd.org. Accessed December 15, 2006Google Scholar and the American Thoracic Society/European Respiratory Society Guidelines19American Thoracic Society-European Respiratory Society Task Force. Standards for the diagnosis and management of patients with COPD (Internet), version 1.2. Available at: http://www-test.thoracic.org/copd/. Accessed September 8, 2005Google Scholar based on FEV1, as follows: stage I (mild), FEV1 ge; 80% predicted; stage II (moderate), FEV1 50 to 80% predicted; stage III (severe), FEV1 30 to 50% predicted; and stage IV (very severe), FEV1 < 30% predicted.PULMONARY REHABILITATIONRehabilitation programs for patients with chronic lung diseases are well-established as a means of enhancing standard therapy in order to control and alleviate symptoms and optimize functional capacity.2American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation..Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines; ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Chest. 1997; 112: 1363-1396Google Scholar,4American Thoracic Society, European Respiratory Society..ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006; 173: 1390-1413Crossref Scopus (1084) Google Scholar,14American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma..Am Rev Respir Dis. 1995; 152: S78-S121Google Scholar,20American Association of Cardiovascular and Pulmonary Rehabilitation.Guidelines for pulmonary rehabilitation programs.2nd ed. Human Kinetics, Champaign, IL1998Google Scholar The primary goal is to restore the patient to the highest possible level of independent function. This goal is accomplished by helping patients become more physically active, and to learn more about their disease, treatment options, and how to cope. Patients are encouraged to become actively involved in providing their own health care, more independent in daily activities, and less dependent on health professionals and expensive medical resources. Rather than focusing solely on reversing the disease process, rehabilitation attempts to reduce symptoms and reduce disability from the disease.Many rehabilitation strategies have been developed for patients with disabling COPD. Programs typically include components such as patient assessment, exercise training, education, nutritional intervention, and psychosocial support. Pulmonary rehabilitation has also been applied successfully to patients with other chronic lung conditions such as interstitial diseases, cystic fibrosis, bronchiectasis, and thoracic cage abnormalities.21Foster S Thomas HM Pulmonary rehabilitation in lung disease other than chronic obstructive pulmonary disease..Am Rev Respir Dis. 1990; 141: 601-604Crossref PubMed Google Scholar In addition, it has been used successfully as part of the evaluation and preparation for surgical treatments such as lung transplantation and lung volume reduction surgery.22Palmer SM Tapson VF Pulmonary rehabilitation in the surgical patient: lung transplantation and lung volume reduction surgery..Respir Care Clin N Am. 1998; 4: 71-83PubMed Google Scholar, 23Biggar DG Malen JF Trulock EP et al.Pulmonary rehabilitation before and after lung transplantation..in: Casaburi R Petty TL Principles and practice of pulmonary rehabilitation. WB Saunders, Philadelphia, PA1993: 459-467Google Scholar, 24Ries AL Pulmonary rehabilitation and lung volume reduction surgery..in: Fessler HE Reilly JJ Jr Sugarbaker DJ Lung volume reduction surgery for emphysema. Marcel Dekker, New York, NY2004: 123-148Google Scholar, 25Celli BR Pulmonary rehabilitation and lung volume reduction surgery in the treatment of patients with chronic obstructive pulmonary disease..Monaldi Arch Chest Dis. 1998; 53: 471-479PubMed Google Scholar, 26Ries AL Make BJ Lee SM et al.The effects of pulmonary rehabilitation in the National Emphysema Treatment Trial..Chest. 2005; 128: 3799-3809Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Pulmonary rehabilitation is appropriate for any stable patient with a chronic lung disease who is disabled by respiratory symptoms. Patients with advanced disease can benefit if they are selected appropriately and if realistic goals are set. Although pulmonary rehabilitation programs have been developed in both outpatient and inpatient settings, most programs, and most of the studies reviewed in this document, pertain to outpatient programs for ambulatory patients.DEFINITIONThe American Thoracic Society and the European Respiratory Society have recently adopted the following definition of pulmonary rehabilitation: Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health-care costs through stabilizing or reversing systemic manifestations of the disease. Comprehensive pulmonary rehabilitation programs include patient assessment, exercise training, education, and psychosocial support.4American Thoracic Society, European Respiratory Society..ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006; 173: 1390-1413Crossref Scopus (1084) Google ScholarThis definition focuses on three important features of successful rehabilitation: 1.Multidisciplinary: Pulmonary rehabilitation programs utilize expertise from various health-care disciplines that is integrated into a comprehensive, cohesive program tailored to the needs of each patient.2.Individual: Patients with disabling lung disease require individual assessment of needs, individual attention, and a program designed to meet realistic individual goals.3.Attention to physical and social function: To be successful, pulmonary rehabilitation pays attention to psychological, emotional, and social problems as well as physical disability, and helps to optimize medical therapy to improve lung function and exercise tolerance.The interdisciplinary team of health-care professionals in pulmonary rehabilitation may include physicians; nurses; respiratory, physical, and occupational therapists; psychologists; exercise specialists; and/or others with appropriate expertise. The specific team make-up depends on the resources and expertise available, but usually includes at least one full-time staff member.27Ries AL Squier HC The team concept in pulmonary rehabilitation..in: Fishman A Pulmonary rehabilitation. Marcel Dekker, New York, NY1996: 55-65Google ScholarMETHODOLOGY AND GRADING OF THE EVIDENCE FOR PULMONARY REHABILITATIONIn 1997, the ACCP and the AACVPR released an evidence-based clinical practice guideline entitled “Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines.”2American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation..Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines; ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Chest. 1997; 112: 1363-1396Google Scholar,3ACCP-AACVPR Pulmonary Rehabilitation Guidelines Panel..Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. J Cardiopulm Rehabil. 1997; 17: 371-405Google Scholar Following the approved process for the review and revision of clinical practice guidelines, in 2002 the ACCP Health and Science Committee determined that there was a need for reassessment of the current literature and an update of the original practice guideline. This new guideline is intended to update the recommendations from the 1997 document and to provide new recommendations based on a comprehensive literature review. The literature review and development of evidence tables were conducted by Carla Herrerias, MPH, the ACCP Clinical Research Analyst. The joint ACCP/AACVPR expert panel used the evidence to develop graded recommendations.Expert Panel CompositionThe guideline panel was organized under the joint sponsorship of the ACCP and the AACVPR. Andrew Ries, MD, MPH, FCCP, Chair of the 1997 panel, served as Chair of the new panel. Panel members were evenly distributed between and selected by the two organizations with a goal of making the panel multidisciplinary and geographically diverse. Drs. Casaburi, Mahler, Make, and Rochester represented the ACCP, and Drs. Bauldoff, Carlin, Emery, and ZuWallack represented the AACVPR. Five panel members (Drs. Carlin, Casaburi, Emery, Mahler, and Make) had served on the previous guideline panel. In addition to several conference calls, the panel met for one 2-day meeting to review the evidence tables and become familiar with the process of grading recommendations. Writing assignments were determined by members' known expertise in specific areas of pulmonary rehabilitation. Each section of the guideline was assigned to one primary author and at least one secondary author. Sections were reviewed by relevant panel members when topics overlapped.Conflict of InterestAt several stages during the guideline development period, panel members were asked to disclose any conflict of interest. These occurred at the time the panel was nominated, at the first face-to-face meeting, the final conference call, and prior to publication. Written forms were completed and are on file at the ACCP.Scope of WorkThe 1997 practice guideline on pulmonary rehabilitation focused on program component areas of lower and upper extremity training, ventilatory muscle training, and various outcomes of comprehensive pulmonary rehabilitation programs, including dyspnea, quality of life, health-care utilization, and survival. Psychosocial and educational aspects of rehabilitation were examined both as program components and as outcomes.For this review, the panel decided to focus on studies that had been published since the previous review, again concentrating on stable patients with COPD. Since there have been many advances and new areas of investigation since the previous document was written, the panel decided to expand the scope of this review rather than just update the previous one. Topics covered in this document include the following: •Outcomes of comprehensive pulmonary rehabilitation programs: lower extremity exercise training; dyspnea; health-related quality of life (HRQOL); health-care utilization and economic analysis; survival; psychosocial outcomes; and long-term benefits from pulmonary rehabilitation;•Duration of pulmonary rehabilitation;•Postrehabilitation maintenance strategies;•Intensity of aerobic exercise training;•Strength training in pulmonary rehabilitation;•Anabolic drugs;•Upper extremity training;•Inspiratory muscle training (IMT);•Education;•Psychosocial and behavioral components of pulmonary rehabilitation;•Oxygen supplementation as an adjunct to pulmonary rehabilitation;•Noninvasive ventilation;•Nutritional supplementation in pulmonary rehabilitation;•Pulmonary rehabilitation for patients with disorders other than COPD; and•Summary and recommendations for future research.Review of EvidenceThe literature review was based on the scope of the work as outlined in the previous section. The literature search was conducted through a comprehensive MEDLINE search from 1996 through 2004, and was supplemented by articles supplied by the guideline panel as well as by a review of bibliographies and reference lists from review articles and other existing systematic reviews. The literature search was limited to articles published in peer-reviewed journals only in the English language, and on human subjects. Inclusion criteria primarily included a population of persons with a diagnosis of COPD determined either by physical examination or by existing diagnostic criteria; however, those with other pulmonary conditions (eg, asthma or interstitial lung disease) were also included. The search included randomized controlled trials (RCTs), metaanalyses, systematic reviews, and observational studies. The search strategy linked pulmonary rehabilitation or a pulmonary rehabilitation program with each key subcomponent, as listed in section on “Scope of Work.” To locate studies other than RCTs, such as systematic reviews and metaanalyses, those key words were used in searching MEDLINE and the Cochrane databases. Informal review articles were included only for hand searching additional references. For the purpose of this review, pulmonary rehabilitation was defined operationally as studies involving exercise training plus at least one additional component. Associated outcomes across all components were dyspnea, exercise tolerance, quality of life and activities of daily life, and health-care utilization. An initial review of 928 abstracts was conducted by the ACCP Clinical Research Analyst and the Research Specialist. Full articles (a total of 202) were formally reviewed and abstracted by the Clinical Research Analyst, and a total of 81 clinical trials were included in all evidence tables. RCTs were scored using a simplified system that was based on methods of randomization, blinding, and documentation of withdrawals/loss to follow-up. This system follows a method that is based on a 3-point scale, which rates randomization (and appropriateness), blinding (and appropriateness), and tracking of withdrawals and loss to follow-up. Studies were graded on a scale of 0 to 5.28Jadad AR Moore RA Carroll D et al.Assessing the quality of reports of randomized clinical trials: is blinding necessary?.Control Clin Trials. 1996; 17: 1-12Abstract Full Text PDF PubMed Scopus (8304) Google Scholar No formal quantitative analysis was performed due to the wide variation in methodologies reported in studies. Given the length of time required to prepare the final manuscript after the conclusion of the systematic literature review in December 2004, from which the tables were constructed, the committee was allowed to include reference to selected articles published in 2005 and 2006 in the text if the additional information provided by the newer publications was felt to be important.Strength of Evidence and Grading of RecommendationsThe ACCP system for grading guideline recommendations is based on the relationship between the strength of the evidence and the balance of benefits to risk and burden (Table 1).29Guyatt G Gutterman D Baumann MH et al.Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force..Chest. 2006; 129: 174-181Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Simply stated, recommendations can be grouped on the following two levels: strong (grade 1); and weak (grade 2). If there is certainty that the benefits do (or do not) outweigh risk, the recommendation is strong. If there is less certainty or the benefits and risks are more equally balanced, the recommendation is weaker. Several important issues must be considered when classifying recommendations. These include the quality of the evidence that supports estimates of benefit, risks, and costs; the importance of the outcomes of the intervention; the magnitude and the precision of estimate of the treatment effect; the risks and burdens of an intended therapy; the risk of the target event; and varying patient values.Table 1Relationship of Strength of the Supporting Evidence to the Balance of Benefits to Risks and Burdens*1A = strong recommendation; 1B = strong recommendation; 1C = strong recommendation; 2A = weak recommendation; 2B = weak recommendation; 2C = weak recommendation.Balance of Benefits to Risks and BurdensStrength of EvidenceBenefits Outweigh Risks/BurdensRisks/Burdens Outweigh BenefitsEvenly BalancedUncertainHigh1A1A2AModerate1B1B2BLow or very1C1C2C2Clow* 1A = strong recommendation; 1B = strong recommendation; 1C = strong recommendation; 2A = weak recommendation; 2B = weak recommendation; 2C = weak recommendation. Open table in a new tab The strength of evidence is classified, based on the quality of the data, into the following three categories: high (grade A); moderate (grade B); and low (grade C). The strongest evidence comes from well-designed RCTs yielding consistent and directly applicable results. In some circumstances, high-q" @default.
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• W2146985504 title "Pulmonary Rehabilitation" @default.
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