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Chest xray in acute wheeze

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Flow Chart

chest xray flow chart

Background

Asthma and preschool wheeze are common childhood conditions both in New Zealand and internationally. It is estimated that approximately 30% of children have episodes of wheeze or asthma at some stage. The term "preschool wheeze" encompasses those preschool children aged ≥1 year who present with wheeze in association with a viral illness, often labelled as "viral induced wheeze." Annually more than 600 children, aged ≥2 years, present to the Children's Emergency Department (CED) at Starship Hospital with asthma or preschool wheeze. Currently one quarter of these children have a chest X-ray (CXR) performed as part of their assessment, often for very limited clinical benefit.

Retrospective reviews of CXR use in acute asthma and preschool wheeze suggest that in most circumstances this investigation does not contribute to diagnosis or management. In addition, it is recognised that performing a CXR on children with asthma and preschool wheeze may be potentially harmful. A CXR delivers a dose of radiation, uses limited healthcare resources and delays patient management. Furthermore, performing a CXR in acute asthma and preschool wheeze often leads to inappropriate use of antibiotics. Children with asthma and preschool wheeze commonly have asymmetric auscultatory findings (including crepitations) and opacities found on CXR. However these children typically have a viral illness, and the opacifications frequently result from atelectasis rather than pneumonic changes, making antibiotic administration unnecessary. Clinical and/or radiological follow up should be arranged for patients with recurrent or persistent symptoms.

This guideline has been designed by combining information from small pilot studies and reaching consensus among the specialists in Children's ED, General Paediatrics and Paediatric Respiratory Medicine at Starship.

We will continue to collect further data on the investigation, management and outcome of wheezy children presenting to CED (including CXR use).

References

Asher MI, Stewart AW, Clayton T, Crane J, Ellwood PI, Mackay R, et al. Has the prevalence and severity of symptoms of asthma changed among children in New Zealand? ISAAC Phase Three. N Z Med J. 2008 Oct 17;121(1284):52-63.

Dale C, Shepherd M. CXR in Asthma. Audit of practice. Children's Emergency Department. Starship Hospital 2009.

Stanley RM, Teach SJ, Mann NC, Alpern ER, Gerardi MJ, Mahajan PV, et al. Variation in ancillary testing among pediatric asthma patients seen in emergency departments. Acad Emerg Med. 2007 Jun;14(6):532-8. Epub 2007 Apr 19

Findley LJ, Sahn SA. The value of chest roentgenograms in acute asthma in adults. Chest. 1981 Nov;80(5):535-6.

Crain EF, Weiss KB, Fagan MJ. Pediatric asthma care in US emergency departments. Current practice in the context of the National Institutes of Health guidelines. Arch Pediatr Adolesc Med. 1995 Aug;149(8):893-901

Buckmaster A, Boon R. Reduce the rads: a quality assurance project on reducing unnecessary chest X-rays in children with asthma. J Paediatr Child Health. 2005 Mar;41(3):107-11.

Dawson KP, Capaldi N. The chest X-ray and childhood acute asthma. Aust Clin Rev. 1993;13(4):153-6

Brooks LJ, Cloutier MM, Afshani E. Significance of roentgenographic abnormalities in children hospitalized for asthma. Chest. 1982 Sep;82(3):315-8.

Tsai SL, Crain EF, Silver EJ, Goldman HS. What can we learn from chest radiographs in hypoxemic asthmatics? Pediatr Radiol. 2002;32(7):498-504

Gershel JC, Goldman HS, Stein RE, Shelov SP, Ziprkowski M. The usefulness of chest radiographs in first asthma attacks. N Engl J Med. 1983 Aug 11;309(6):336-9

Gildenhuys J, Lee M, Isbister GK. Does implementation of a paediatric asthma clinical practice guideline worksheet change clinical practice? Int J Emerg Med. 2009 Apr;2(1):33-9.

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Document Control

  • Date last published: 01 June 2010
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Mike Shepherd
  • Editor: Greg Williams
  • Review frequency: 2 years

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