| Evidence classification method： |
Evidence and recommendation grades were determined using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system (Table 1). Ultimately the propriety of any specific procedure must be determined by the practitioner, taking into account all of the circumstances presented by each individual patient.
TABLE 1. The GRADE system: grading recommendations
No. Description Benefit vs. risks and burdens Methodologic quality of supporting evidence Implications
1A Strong recommendation, high-quality evidence Benefits clearly outweigh risks and burdens or vice versa
RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation
1B Strong recommendation, moderate-quality evidence Benefits clearly outweigh risks and burdens or vice versa
RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation
1C Strong recommendation, low- or very-low-quality evidence Benefits clearly outweigh risks and burdens or vice versa
Observational studies or case series Strong recommendation but may change when higher quality evidence becomes available
2A Weak recommendation, high-quality evidence Benefits closely balanced with risks and burdens
RCTs without important limitations or overwhelming evidence from observational studies
Weak recommendation, best action may differ depending on circumstances or patient or societal values
2B Weak recommendations, moderate-quality evidence
Benefits closely balanced with risks and burdens
RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patient or societal values
2C Weak recommendation, low- or very-low-quality
evidence
Uncertainty in the estimates of benefits, risks and burdens Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable; benefits and risks may be closely balanced
Adapted with permission from Chest. 2006;129:174–181.
GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial.
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