This is a blog post and a podcast episode designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

Special thanks to Todd Florin, MD, MSCE who contributed to this post – he is also an expert on respiratory and infectious emergencies.

Learning Objectives

1. Understand some of the unintended consequences associated with ordering an unnecessary chest xray
2. Be familiar with evidence to help decide who needs a CXR and who does not
3. Learn some strategies for reducing unnecessary CXRs

Anticipating yet another busy shift in your ED, you survey the multitude of children awaiting evaluation on the electronic tracking board and a waiting room filled to capacity. A common phenomenon in EDs around the country, this scenario is only made worse by typical spikes in patient volumes during respiratory viral seasons.  Many of the children you will evaluate during your shift are among the estimated 10 million United States (US)  ED visits made by children with asthma, bronchiolitis, and croup, the most common pediatric respiratory conditions presenting to acute care settings.  As many as 40% of these children will receive a chest x-ray (CXR) during their ED visit despite clinical guidelines advising most of these tests are low value.

Research suggests most CXRs are performed because ED clinicians (and many parents) are concerned for the possibility of missing pneumonia or another diagnosis requiring specific management.  ED providers and radiologists commonly face the scenario of interpreting a CXR in a child with respiratory complaints prompting the questions: Does that infiltrate represent bacterial pneumonia, inflammation, or simply atelectasis? While no validated clinical prediction rule is available yet to determine which children should receive a CXR, we do know that the presence of bacterial pneumonia is uncommon in otherwise healthy, immunized children with usual presentations of asthma, bronchiolitis and croup.  Numerous studies have found that radiographs performed in these clinical conditions rarely reveal information necessitating a change in ED management despite high CXR utilization and wide variation in both children’s specialty hospitals and general EDs.  But it’s just a CXR right?

Ordering a CXR is not innocuous, resulting in increased cost and length of stay, exposure to radiation, and a cascade of other potential downstream problems such as the misinterpretation of radiographs and subsequent use of unnecessary antibiotics.  Understanding root causes of CXR use in the ED clinical setting is key to mitigating overuse of this test.  Drivers of CXR overuse are myriad and can be thought of at the system, provider, and patient levels.  System level innovations such as the electronic health platform, including order entry, were intended to improve efficiency but may result in the unintended consequence of making it easier to order a chest radiograph without substantiating the need or in conflict with best clinical practice guidelines.  Provider level factors such as newly autonomous trainees, advanced practice professionals, and clinicians with infrequent exposure to pediatric respiratory illnesses may lead to overreliance on tests.  The ED setting presents an overwhelming burden of demands on providers’ time, limiting their ability to engage in comprehensive shared decision making with families that may have mitigated testing if only they had the time to explain their reasoning.  Legal implications of a missed diagnosis also play a role in testing decisions, and providers may be pressured to perform these tests due to expectations of outpatient referring physicians or those receiving patients to the hospital from the ED.   Concerned parents, fueled by a mountain of medical information online, often arrive expecting tests rather than provider expertise to determine the presence or absence of pneumonia.  Some families, particularly those with limited means, ask for testing and treatment they believe will expedite resolution of their child’s illness so as to mitigate child care and transportation issues, loss of work or pay or some combination of all of these.

Despite efforts to raise awareness of low value imaging practices in children with asthma, bronchiolitis and croup through available national and international recommendations, CXR use remains persistently high in the US and Canada.   This US and Canadian endorsed Choosing Wisely recommendation aims to communicate both to the public and medical community the need for change to finally reduce CXR utilization and variation in practice in these otherwise healthy children. 

What we can do now as ED clinicians is focus our efforts to reduce CXRs in those uncomplicated children presenting with typical symptoms of asthma, bronchiolitis and croup who are likely to be discharged from the ED and reserve consideration of this test for those with unique factors such as being unimmunized, having comorbidities or complex disease, and/or atypical or prolonged symptoms.  System changes to electronic ordering have been shown to induce more permanent clinical practice change and continual updates to these systems are necessary to keep pace with knowledge evolution and best practice. Standardized language in reporting of pedatricpediatric chest radiographs, once ordered, can mitigate the cascade of overuse by reducing pressure on providers to prescribe antibiotics for a radiograph that did not “rule out” pneumonia.  Resources to reassure parents of the accuracy of the history and physical examination in ruling out pneumonia, including messaging that testing is used carefully to ensure a child’s safety and comfort, could reduce pressures on busy providers.  However, the impact of such resources has not yet been deeply explored.  Reducing overuse of chest radiographs in children with minor respiratory conditions, and the ensuing cascade of inintededunintended consequences, will require understanding its key drivers and developing appropriately targeted interventions. 

The Choosing Wisely recommendation:

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

This episode of PEM Currents: The Pediatric Emergency Medicine Podcast approaches the topic from another angle and also discusses how we can avoid overuse of chest X-rays in children with respiratory illnesses, including more practical tips and advice on how to talk to families.

 

Pertussis – PEM Currents: The Pediatric Emergency Medicine Podcast

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore pertussis, also known as whooping cough – a disease that remains a public health challenge despite widespread vaccination efforts. We will review the clinical presentation, diagnostic strategies, management protocols, infection control practices, and vaccination updates. This episode also covers what healthcare providers need […]

1. Pertussis 11:52
2. Gastroesophegeal Reflux and Gastritis 27:00
3. ECPR 07:35
4. Syphilis 09:25
5. Cervical Spine Injuries

References

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. PMID: 28763554.

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. PMID: 17382126.

Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. A Prediction Model for Pediatric Radiographic Pneumonia. Pediatrics. 2022 Jan 1;149(1):e2021051405. doi: 10.1542/peds.2021-051405. PMID: 34845493

Florin TA, Carron H, Huang G, Shah SS, Ruddy R, Ambroggio L. Pneumonia in Children Presenting to the Emergency Department with an Asthma Exacerbation. JAMA Pediatr. 2016;170(8):803-805. https://doi:10.1001/jamapediatrics.2016.0310