TABLE 4

Pulmonary exacerbations

Statement number	Statement	Type of statement	Strength of recommendation	Quality of evidence	Type of patient	Most relevant supporting articles
3.1	CR may not help with the detection of pulmonary exacerbation, especially in CF patients with more severe disease.	Recommendation	Grade D	Low	Diagnosis	[149]
3.2	CT can detect acute structural lung abnormalities during and after pulmonary exacerbation (e.g. increase of bronchial wall thickening and mucus plugging) in cooperative, and uncooperative, patients.	Statement of fact	NA	High	Diagnosis	[89, 95, 96, 150–156]
3.3	CT can be used to define outcome measures of pulmonary damage in clinical trials and test therapeutic interventions in patients with persistent respiratory symptoms and reduced lung function despite appropriate therapy.	Recommendation	Grade C	Low	Diagnosis and monitoring treatment response	[55, 65, 89, 95, 96, 150–154, 157]
3.4	Routine use of CT for short term follow-up during pulmonary exacerbation is not recommended due to the risk of high cumulative radiation dose. Clinicians should consider the risk/benefit ratio related to dose when prescribing CT in pulmonary exacerbation.	Recommendation	Grade D	Moderate	Monitoring treatment response	[14, 29, 35, 36, 40–44, 158]
3.5	MRI can be used as a surrogate marker for disease severity and response to treatment during short-term follow-up of symptomatic, or declining, cooperative CF patients. In uncooperative patients, the risk related to moderate sedation or anaesthesia needs to be considered.	Recommendation	Grade A	High	Diagnosis and monitoring treatment response	[118, 119, 130, 136, 159]
3.6	MRI can be used as a clinically relevant outcome predictor for pulmonary exacerbations in cooperative, declining CF patients.	Statement of fact	NA	High	Diagnosis and monitoring treatment response	[106, 116, 119, 130, 139]

CF: cystic fibrosis; CR: chest radiograph; CT: computed tomography; MRI: magnetic resonance imaging; NA: not available.