Population Covered By The Guidance
This pathway provides guidance on imaging patients with acute respiratory illness and provides guidelines as to who would benefit from plain chest radiography.
Lead Researcher: Gurjeet Dulku
Experts & Contributors: Buirski, Emmeline Lee, William MacDonald, Richard Mendelson, Brett Montgomerry, Peter Scally, Yuranga Weerakkody
Editorial Panel: Core Membership
Date reviewed: June 2015
Date Published: February 2016
Pneumococcal Pneumonia
Pneumococcal Pneumonia
Pneumocystis Pneumonia
Tuberculous Pneumonia
Lung Abscess
Lung Abscess
Bronchopneumonia
Bronchopneumonia
Collapse Lung
Collapse Lung
Collapse Lung
Role of Imaging in Acute Respiratory Illness
- Chest radiography is over utilized in the management of acute respiratory illness
- Certain clinical symptoms and signs can suggest a diagnosis of pneumonia but none can definitely rule in or out the diagnosis
- 5% of patients with acute respiratory illness have pneumonia from a primary care setting. This increases to 28% of patients in the accident and emergency environment
- CT is not routine in the setting of acute respiratory illness
- Lung ultrasonography (LUS) has shown to be promising in the evaluation of pneumothorax, pleural effusion and consolidations but with varying outcomes for the diagnosis of pneumonia. Therefore, an inconspicuous LUS does not exclude pneumonia and necessitates a chest radiography or chest CT scan for further evaluation
Date of literature search: June 2015
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Heckerling PS, Tape TG, Wigton RS, et al. Clinical prediction rule for pulmonary infiltrates. Ann Intern Med. 1990;113:664-70. (Level II evidence). View the reference
- Rothrock SG, Green SM, Costanzo KA, et al. High yield criteria for obtaining non-trauma chest radiography in the adult emergency department population. J Emerg Med. 2002;23:117-24. (Level II evidence). View the reference
- Cereser L, Zuiani C, Graziani G, Girometti R, Como G, Zaja F, et al. Impact of clinical data on chest radiography sensitivity in detecting pulmonary abnormalities in immunocompromised patients with suspected pneumonia. Radiol Med. 2010;115(2):205-14. (Level III evidence). View the reference
- Wilkins TR, Wilkins RL. Clinical and radiographic evidence of pneumonia. Radiol Technol. 2005;77(2):106-10. (Review article). View the reference
- Heckerling PS. The need for chest roentgenograms in adults with acute respiratory illness: clinical predictors. Arch Intern Med. 1986;146:1321-4. (Level IV evidence). View the reference
- Butcher BL, Nichol KL, Parenti CM. High yield of chest radiography in walk-in clinic patients with chest symptoms. J Gen Intern Med. 1993;8:115-9. (Level III evidence). View the reference
- Benacerraf BR, McLoud TC, Rhea JT, et al. An assessment of the contribution of chest radiography in outpatients with acute complaints: a prospective study. Radiology. 1981;138:293-9. (Level IV evidence). View the reference
- Okimoto N, Yamato K, Kurihara T, Honda Y, Osaki K, Asaoka N, et al. Clinical predictors for the detection of community-acquired pneumonia in adults as a guide to ordering chest radiographs. Respirology. 2006;11(3):322-4. (Level III evidence). View the reference
- O'Brien WT, Sr., Rohweder DA, Lattin GE, Jr., Thornton JA, Dutton JP, Ebert-Long DL, et al. Clinical indicators of radiographic findings in patients with suspected community-acquired pneumonia: who needs a chest x-ray? J Am Coll Radiol. 2006;3(9):703-6. (Level II evidence). View the reference
- van Vugt SF, Verheij TJ, de Jong PA, Butler CC, Hood K, Coenen S, et al. Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography. Eur Respir J. 2013;42(4):1076-82. (Level II evidence). View the reference
- Basi SK, Marrie TJ, Huang JQ, Majumdar SR. Patients admitted to hospital with suspected pneumonia and normal chest radiographs: epidemiology, microbiology, and outcomes. Am J Med. 2004;117(5):305-11. (Level III evidence). View the reference
- Cao AM, Choy JP, Mohanakrishnan LN, Bain RF, van Driel ML. Chest radiographs for acute lower respiratory tract infections. Cochrane Database Syst Rev. 2013;12:CD009119. (Level II evidence). View the reference
- Simpson JCG, Hulse P, Taylor PM, Woodhead M. Do radiographic features of acute infection influence management of lower respiratory tract infections in the community? Eur Respir J. 1998;12:1384-7. (Level IV evidence). View the reference
- Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278:1440-5. (Review article). View the reference
- Speets AM, Hoes AW, van der Graaf Y, Kalmijn S, Sachs AP, Mali WP. Chest radiography and pneumonia in primary care: diagnostic yield and consequences for patient management. Eur Respir J. 2006;28(5):933-8. (Level II/III evidence). View the reference
- Graffelman AW, Willemssen FE, Zonderland HM, Neven AK, Kroes AC, van den Broek PJ. Limited value of chest radiography in predicting aetiology of lower respiratory tract infection in general practice. Br J Gen Pract. 2008;58(547):93-7. (Level II/III evidence). View the reference
- Hagaman JT, Rouan GW, Shipley RT, Panos RJ. Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia. Am J Med Sci. 2009;337(4):236-40. (Level III evidence). View the reference
- Bruns AH, Oosterheert JJ, Prokop M, Lammers JW, Hak E, Hoepelman AI. Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia. Clin Infect Dis. 2007;45(8):983-91. (Level III evidence). View the reference
- Aronson S, Gennis P, Kelly D, et al. The value of routine admission chest radiographs in adult asthmatics. Ann Emerg Med. 1989;18:1206-8. (Level IV evidence). View the reference
- Findley LJ, Sahn SA. The value of chest roentgenograms in acute asthma in adults. Chest. 1981;80:535-6. (Level IV evidence). View the reference
- Brixey AG, Luo Y, Skouras V, Awdankiewicz A, Light RW. The efficacy of chest radiographs in detecting parapneumonic effusions. Respirology. 2011;16(6):1000-4. (Level III evidence). View the reference
- Corradi F, Brusasco C, Garlaschi A, Paparo F, Ball L, Santori G, et al. Quantitative analysis of lung ultrasonography for the detection of community-acquired pneumonia: a pilot study. Biomed Res Int. 2015;2015:868707. (Level II evidence). View the reference
- Reissig A, Copetti R. Lung ultrasound in community-acquired pneumonia and in interstitial lung diseases. Respiration. 2014;87(3):179-89. (Review article). View the reference
- Turner JP, Dankoff J. Thoracic ultrasound. Emerg Med Clin North Am. 2012;30(2):451-73, ix. (Review article). View the reference
- Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25. View the reference
- Volpicelli G, Caramello V, Cardinale L, Cravino M. Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain. Ultrasound Med Biol. 2008;34(11):1717-23. (Level II/III evidence). View the reference
- Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142(4):965-72. (Level II evidence). View the reference
- Chavez MA, Shams N, Ellington LE, Naithani N, Gilman RH, Steinhoff MC, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res. 2014;15:50. (Level I evidence). View the reference
- Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ed? Chest. 2011;139(5):1140-7. (Level II evidence). View the reference
- Laursen CB, Sloth E, Lambrechtsen J, Lassen AT, Madsen PH, Henriksen DP, et al. Focused sonography of the heart, lungs, and deep veins identifies missed life-threatening conditions in admitted patients with acute respiratory symptoms. Chest. 2013;144(6):1868-75. (Level II evidence). View the reference
Pathway User Guide
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Chest Radiography
Chest Radiography
The first line investigation where necessary for patients with acute respiratory illness
- Patients with acute respiratory illness but without pneumonia often have unnecessary chest radiographs and these result in unnecessary cost and radiation exposure
- Many patients with acute respiratory illness receive a chest radiograph, usually to diagnose or exclude pneumonia
- Approximately 5% of patients who present to their primary care physician with an acute respiratory illness will have pneumonia as chest radiography was not very useful for diagnosing pneumonia in patients with a low clinical probability of pneumonia
- Of patients with an acute respiratory illness who present to an Emergency Department, as many as 28% will have pneumonia
- Admission radiographs lacks sensitivity and may not demonstrate parenchymal opacifications in 21% of patients. Moreover, greater than half of patients admitted with a negative chest radiograph will develop radiographic infiltrates within 48 hours. , Because of the low sensitivity and inter-observer variability, some of the infiltrates can be missed
- Routine short-term follow-up chest radiographs (18
- Patients with acute asthma occasionally have significant abnormalities on chest radiography and may only require imaging if there is suspected pneumonia or pneumothorax ,
- More than 10% of para-pneumonic effusions are missed on chest radiographs (lateral, PA and AP) with the majority presenting effusions missed in each view were on films with lower lobe consolidation in which clinicians should consider obtaining a lung ultrasound
Chest Computed Tomography (CT)
Chest Computed Tomography (CT)
Indications for chest CT include
- Infiltrate, opacity, collapse or consolidation on plain chest radiograph that does not resolve after treatment for infection, or fit with the clinical picture
- Non-resolving infection or recurring infections in the same locations
- Suspected emphysema
- Suspected bronchiectasis
- Immunocompromised patients with fever of unknown origin and a potential chest source even if plain chest radiography is normal
CT is not routine in the setting of an acute respiratory illness. Indications for CT include
- Infiltrate, opacity, collapse, or consolidation on plain chest radiograph that does not resolve after treatment for infection, or fit with the clinical picture
- Non-resolving infection, or recurring infections in the same location
- Suspected empyema
- Suspected bronchiectasis
- Immunocompromised patients with fever of unknown origin and a potential chest source even if plain chest radiography is normal