UMEM Educational Pearls

Category: Pediatrics

Title: When do I get a chest xray in a child with asthma?

Keywords: Asthma, chest xray (PubMed Search)

Posted: 7/20/2018 by Jenny Guyther, MD (Updated: 2/23/2024)
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Question

Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.

CXR in asthma are indicated for:

-severe persistent respiratory distress, room air saturations <91%

- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy

- concern for pneumomediastinum or pneumothorax

 

Answer

This study tried to use quality improvement measures to decrease the rate of chest xrays in children seen for asthma.

6680 children with billing codes for asthma had 1359 CXRs.  Using a clinical practice guideline and then targeted intervention, the group was able to reduce CXR use from 29% to 16%.  In subgroup analysis, the CXR use decreased from 21.3% to 12.5% for discharged patients and 53.5% to 31.1% for admitted patients.

The National Asthma Education and Prevention Program has created guidelines to help providers manage acute asthma exacerbations stating that CXRs should be reserved for patients suspected of having an alternate diagnosis such as pneumothorax, pneumomediastinum or congestive heart failure.  This does not include the suspicion for associated pneumonia!  A study of >14,000 patients with asthma showed that less than 2% also had pneumonia.

The interventions done in this study were:

              An electronic asthma order set was created to include “CXR not routinely recommended”

              Clinical practice guidelines were reviewed with residents, faculty, nursing, and respiratory therapy at regular intervals

              Copies of the clinical practice guidelines were posted in a highly visualized area

              CXRs removed from the default order set

              Wheezing was removed as an indication for CXR

              CXR in asthma are indicated for: severe persistent respiratory distress, room air saturations <91%, focal findings not improving on >11 hours of standard asthma therapy or concern for pneumomediastinum or pneumothorax

 

References

Watnick CS, Arnold DH, Latuska RL, O’Connor M, Johnson DP.  Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children with Asthma.  Pediatrics.  Published online July 11, 2018.