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Choosing Wisely – Radiographs in children with respiratory symptoms

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The Choosing Wisely® campaign is an initiative that promotes collaborative conversations between clinicians and families to safely avoid unnecessary and potentially harmful tests.

The American Academy of Paediatrics Section on Emergency Medicine (AAP SOEM) created a list of five key recommendations for Paediatric Emergency Medicine after a structured review process and expert consensus opinion.

This series of DFTB articles aims to increase awareness of the Choosing Wisely® recommendations. Each article will take a deeper dive into each recommendation’s supporting evidence and practical implications.

 Do not obtain radiographs in children with bronchiolitis, croup, asthma, or first-time wheezing.

The parents of 9-month-old Josie bring her into the Emergency Department with coryzal symptoms and difficulty breathing. She can tolerate approximately 75% of her feeds and does not have an oxygen requirement. She has no risk factors and was born at term without complication.

Worried about the cause of her illness, her parents ask you whether a chest x-ray would be useful.

What do the guidelines say?

The National Institute for Health and Care Excellence (UK), American Academy of Paediatrics (USA), Canadian Paediatric Society (Canada), and the PREDICT Network (Australia) are all in agreement in recommending against the routine use of radiographs for bronchiolitis croup, asthma, or first-time wheezing. All of these guidelines send a clear message. Radiograph use offers little benefit and can lead to an incorrect diagnosis and treatment that is of no benefit or even harmful. A recent systematic review and meta-analysis examined 32 bronchiolitis international clinical practice guidelines. None recommended the routine use of radiographs in the diagnosis of bronchiolitis.

What is the evidence for avoiding chest X-rays?

Non-bacterial causes often trigger bronchiolitis, croup, asthma, or first-time wheezing. Although a CXR is often requested to rule out pneumonia, it can lead to an incorrect diagnosis, unnecessary antibiotic prescription, additional costs, and an increased length.

A secondary analysis of a nationwide study of Emergency Department attendance in America from 2006 to 2008 found that CXRs increase the average length of stay by 27 minutes. Overcrowding and limited staffing threaten to increase the length of stay if unnecessary imaging is obtained.

Radiographic findings in bronchiolitis and other viral aetiologies may include peribronchial infiltrates, hyperinflation, and atelectasis. These findings are often mistaken for signs of bacterial infection. A prospective cohort study of infants with typical bronchiolitis demonstrated that having a CXR increased the incorrect diagnosis of bacterial pneumonia from 2% to 15% and estimated that 133 children would need a CXR to identify one child with an alternative diagnosis. Additionally, a large multi-centre, international retrospective cohort study showed that a CXR was associated with increased antibiotic use regardless of bronchiolitis severity.

The rates of CXR use in bronchiolitis in hospitalised infants with varies widely, with a mean of 54.9% (ranging from 3.5% to 81%). Inter-observer interpretation is also poor and unreliable in diagnosing pneumonia. A large survey of 537 attending physicians (consultant level) in America looked at the attitude and knowledge about obtaining a CXR for children presenting with their first wheezing episode. Over three-quarters of clinicians thought that a CXR was the standard of care. Among those who do not always obtain a CXR, one-fifth still routinely obtained them under a certain age (2 weeks to 12 years, median of 1 year).

Higher rates of adverse events have not been seen in Emergency Departments where the use of imaging is lower.

Which children need a chest X-ray?

Although radiographs are not recommended for typical cases, some patients may benefit from a CXR to help guide further investigations and management. For example, children with underlying respiratory/cardiac disease, a history of prematurity (<37 weeks of gestation), significant hypoxia, focal abnormalities, prolonged course of illness, immunosuppression or severe respiratory distress may benefit from a CXR to identify bacterial pneumonia or make an alternative diagnosis (e.g., cardiac). Additionally, if there isn’t a clear cause or a lack of viral symptoms, imaging should be considered on a case-by-case basis to assess for an alternative diagnosis.

How can we reduce the use of radiographs?

Quality Improvement (QI) projects to reduce the use of radiographs should be implemented in paediatric emergency departments. A recent QI project using the Plan-Do-Study-Act (PDSA) model included provider education, assessment of engagement and practice variation via survey, and performance evaluation. These interventions led to a 25% reduction in radiograph use in children presenting with asthma or bronchiolitis. Another QI project using higher reliability interventions (e.g., workflow redesign, transparency of performance, standardized approach to bronchiolitis) showed a sustained reduction of radiograph use. These higher-reliability interventions were more effective than educational campaigns.

What should we say to parents and caregivers?

Variation in practice can make it hard to communicate a standard message. This may be because of training, clinician discomfort with the “watch and wait approach”, or difficulties in managing expectations.

Discussing the diagnosis and natural course of the illness may help foster a shared understanding of the limited role of imaging. This can be supported by patient information leaflets in multiple languages.

Some examples of key points to communicate are detailed in the infographic below.

Take home points

Also, take a look at these resources

References

Allie EH, Dingle HE, Johnson WN, et al. ED chest radiography for children with asthma exacerbation is infrequently associated with change of management. Am J Emerg Med. 2018;36(5):769-773. doi: 10.1016/j.ajem.2017.10.009

Arora R, Vega C, Farooqi A, et al. A Quality Improvement initiative to decrease chest x-ray utilization for asthma and bronchiolitis in a Pediatric Emergency Department. Pediatrics July 2020; 146 (1_MeetingAbstract): 206–209. 10.1542/peds.146.1MA3.206

Bada C, Carreazo NY, Chalco JP, Huicho L. Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and concurrent wheezing. Sao Paulo Med J. 2007;125(3):150-154. doi: 10.1590/s1516-31802007000300005

Beyyumi, E., Tawil, M. I., AlDhanhani, H., Jameel, S., Mouhssine, M., AlNuaimi, H. M., Hamdoun, O., Alabdouli, A., Alsamri, M. T., Ghatasheh, G. A., Zoubeidi, T., & Souid, A. K. (2021). A Single-Institution Experience in the Use of Chest Radiographs for Hospitalized Children Labeled as Asthma Exacerbation. Frontiers in pediatrics9, 722480. https://doi.org/10.3389/fped.2021.722480

Cohen E, Rodean J, Diong C, et al. Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada [published correction appears in JAMA Pediatr. 2019 Aug 1;173(8):801]. JAMA Pediatr. 2019;173(8):e191439. doi:10.1001/jamapediatrics.2019.1439

Amir Kirolos and others, A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis, The Journal of Infectious Diseases, Volume 222, Issue Supplement_7, 1 November 2020, Pages S672–S679, https://doi.org/10.1093/infdis/jiz240

Frazier SB, Walls C, Jain S, Plemmons G, Johnson DP. Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions. Pediatrics. 2021;148(3):e2020014597. doi:10.1542/peds.2020-014597

Friedman JN, Davis T, Somaskanthan A, Ma A. Avoid doing chest x rays in infants with typical bronchiolitis. BMJ. 2021;375:e064132. Published 2021 Oct 22. doi:10.1136/bmj-2021-064132

Kocher KE, Meurer WJ, Desmond JS, et al. Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med. 2012;19:525–534.

Majerus CR, Tredway TL, Yun NK, Gerard JM. Utility of Chest Radiographs in Children Presenting to a Pediatric Emergency Department With Acute Asthma Exacerbation and Chest Pain. Pediatr Emerg Care. 2021;37(7):e372-e375. doi:10.1097/PEC.0000000000001615

National Heart, Lung, and Blood Institute. Expert Panel Report 4: Guidelines for the Diagnosis and Management of Asthma; National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007:391

Patel NH, Hassoun A, Chao JH. The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians. Pediatr Emerg Care. 2020;36(1):16-20. doi:10.1097/PEC.0000000000002015

Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. DOI: https://doi.org/10.1542/peds.2014-2742

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. DOI: 10.1016/j.jpeds.2007.01.005

Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. DOI: 10.1001/jama.2017.9039

Trottier ED, Chan K, Allain D, Chauvin-Kimoff L. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438-439. DOI: 10.1093/pch/pxab058

Zipursky A, Kuppermann N, Finkelstein Y et al. Pediatric Emergency Research Networks (PERN). International practice patterns of antibiotic therapy and laboratory testing in bronchiolitis. Pediatrics 2020;146:e20193684. doi: 10.1542/peds.2019-3684 pmid: 32661190

All articles were reviewed and edited by Spyridon Karageorgos.

Authors

  • Owen Hibberd is an Emergency Medicine Trainee in Cambridge, currently studying on the QMUL PEM MSc. Interested in Paediatric Emergency Medicine, Pre-Hospital Emergency Medicine and Medical Education. He/him.

  • Spyridon is a Paediatric Resident in Athens, interested in Paediatric Emergency Medicine, reducing antibiotic use in paediatric patients and in Medical Education. Currently studying on the QMUL PEM MSc. He/him.

  • Brad Sobolewski, MD, MEd is an Associate Professor of Pediatric Emergency Medicine and an Associate Director for the Pediatric Residency Training Program at Cincinnati Children's Hospital Medical Center. He is on Twitter/X as @PEMTweets and authors the Pediatric Emergency Medicine site PEMBlog and is the host of PEM Currents: The Pediatric Emergency Medicine Podcast.

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1 thought on “Choosing Wisely – Radiographs in children with respiratory symptoms”

  1. Hi, whilst I agree with the majority of this, I’m interested in the recommendation to perform CXR for suspected bacterial pneumonia. Part of the issue with CXR in small infants are they are poorly reproducible (a small child cannot breath in on command) and the features of bronchiolitis mimic pneumonia, making it incredibly difficult to distinguish based on xray findings. Instead, clinical features should guide management and antibiotics should be commenced for children who have features highly suggestive of bacterial pneumonia.

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