Indications for Paediatric Chest X-rays

Publication: 23/07/2015  --
Last review: 11/09/2019  
Next review: 11/09/2022  
Clinical Guideline
CURRENT 
ID: 4268 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Indications for Paediatric Chest X-rays

  1. Aims
  2. Objectives
  3. Background
  4. Main indications
    1. Feverish child with no focus - traffic light assessment
    1. Acute wheeze (Asthma and Bronchiolitis)
    2. Foreign body airway obstruction
    3. Confirmation of NG tube placement
  5. Indications for chest x-ray under 3 months
  6. Indications for chest x-ray over 3 months
  7. References

Summary of Guideline

This guideline is designed to offer guidance on the use of chest x-rays in children, a large number of which are currently being requested or performed inappropriately. The guideline charts out the main indications for undertaking chest x-rays in children and describes some common scenarios where x-rays may or may not be indicated. 

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Aims

To offer guidance on the use of chest x-rays in children

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Objectives

  • To cover main indications for chest x-rays
  • To provide clarification on when to do a chest x-ray in:
    •  
      • The feverish child with no focus
      • Suspected pneumonia
      • Acute wheeze; including Asthma and Bronchiolitis
      • Suspected Foreign Body Inhalation

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Background

A chest x-ray represents between 0.01 and 0.03mSv Effective Dose of radiation, the equivalent of 3-4 days background radiation. The average cost for a chest radiograph is around £48.

An audit reviewing 25 chest x-rays requested from A&E/CAT (Childrens Assessment & Treatment unit) during a 1 week period in October 2016, demonstrated that only 52% were actually necessary. Therefore, 12 children were exposed to radiation unnecessarily, at a cost of £625 to the trust. Annually, this costs the Children’s Hospital an estimated £50,000, taking into account chest x-rays performed which are not requested in CAT or A+E.

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Main Indications

  1. Acute chest infection (see below)
    1. Feverish child with no focus
    2. Suspected pneumonia
  2. Life threatening asthma (see below for acute wheeze)
  3. Inhaled foreign body (see below)
  4. Check position of nasogastric tube placement (see below)
  5. Suspected pneumothorax
  6. Suspected perforation
  7. Trauma to chest
  8. Suspected heart failure
  9. Suspected malignancy or Tuberculosis
  10. Check position of PICC line
  11. Check position of gastric pH probe

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Feverish child with no focus

Traffic light assessment (fever no focus CAT pathway - based on NICE guidance for feverish child): For use in children aged 0 - 16 yrs

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Indications for chest x-ray under 3 months in “Fever without Focus”

  • If respiratory signs are present
  • In children with no respiratory signs consider a CXR (after discussion with a Paediatric Registrar or Consultant) if the child is unwell or the diagnosis is not clear (E.g. as part of a sepsis screen, possible congenital heart disease, etc.). However the priority should be treating and stabilising a sick child.

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Indications for chest x-ray over 3 months in “Fever without Focus”

  1. Assessed as ‘Green’
    • Chest x-ray is not indicated
  2. Assessed as ‘Amber’
    • Perform a chest x-ray if there is a fever greater than 39°C and WBC greater than 20 × 109/litre. (unless deemed unnecessary by an experienced paediatrician i.e Registrar or Consultant)
  3. Assessed as ‘Red’
    • Perform a chest X-ray irrespective of body temperature and WBC

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Suspected Pneumonia

A chest x-ray should not be performed to confirm the presence of pneumonia

Indications for a chest x-ray in suspected pneumonia include:

  1. Exclusion of empyema or pleural effusion
  2. Failure to respond to therapy within 48hours
  3. Acute severe deterioration with either;
    1. An increase in oxygen requirements
    2. Increased respiratory distress
  4. Pre-existing chronic lung condition with acute deterioration

Clinical Signs for suspected pneumonia

  • Tachypnoea;
    • <5 months: RR> 60
    • 6-12 months: RR> 50
    • >12months: RR>40
  • Crackles in the chest
  • Nasal flaring
  • Chest in-drawing
  • Cyanosis
  • Oxygen saturation of 95% or less when breathing air.

Recommendations:

  1. Chest radiography should not be considered a routine investigation in children thought to have pneumonia
  2. Children with signs and symptoms of pneumonia who are not admitted to hospital should not have a chest x-ray.
  3. A lateral x-ray should not be performed routinely.
  4. Follow-up radiography is not required in those who were previously healthy and who are recovering well, but should be considered in those with a round pneumonia, collapse or persisting symptoms.

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Acute wheeze

Asthma

Chest x-rays rarely provide additional useful information and are not routinely indicated.

A chest x-ray should only be considered if:

  • There is a surgical emphysema
  • Persisting unilateral signs suggesting pneumothorax
  • Suspected pneumomediastinum
  • Life threatening asthma not responding to treatment
  • Requiring ventilation

Bronchiolitis

Chest x-rays are not routinely recommended but should be considered if Intensive Care is being proposed for the child.

NB: Changes on a chest x-ray may mimic pneumonia and should not be used to determine the need for antibiotics

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Foreign body airway obstruction

A chest x-ray is not the first line of investigation if complete or partial obstruction is suspected in either the larynx or main bronchus, in this situation an urgent Bronchoscopy is required. However, while awaiting a respiratory or surgical review consider performing a chest x-ray (after discussion with a senior doctor) as it may provide valuable information i.e presence of a surgical emphysema or a potential tension pneumothorax. It may also show the foreign body if it is radiodense.

If suspecting an airway obstruction below the main bronchus a chest x-ray is helpful, especially if the foreign body is radio-opaque. Objects like vegetables, peanuts, plastics, etc will not show up on the x-ray but x-ray changes may help guide specialist opinion.

Clinical features suggestive of obstruction in children aged 6 months to 4 years, below the main bronchus:

  • History of coughing, wheeze, choking, playing with small objects unsupervised
  • History of persistent wheeze, cough, fever or dyspnoea not otherwise explained
  • Asymmetrical chest movements
  • Lung/segmental collapse or overinflation
  • Chest signs of wheeze or decreased breath sounds

If a chest x-ray is required to exclude a foreign body below the main bronchus, then request both inspiratory and expiratory films if possible (only possible in a compliant older child) .4 Specifically look for:

  • An opaque foreign body
  • Segmental or lobar collapse
  • Localised emphysema in expiration

REMEMBER A NEGATIVE CHEST X-RAY DOES NOT EXCLUDE A FOREIGN BODY

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Confirmation of NG tube

The main indication for an x-ray is failure to obtain an aspirate OR an aspirate with a pH >5, which may arise in the following circumstances:

  • On insertion
  • Following vomiting / endotracheal suction / violent coughing
  • Following evidence of tube displacement

Please ensure the x-ray request states to check NG tube placement, to ensure the appropriate x-ray captures the area below the diaphragm.

Following x-ray, please see the LTHT guidelines for ‘insertion of a nasogastric tube (NGT) and ongoing care for infants and children’, for recommendations on interpreting the x-ray.

Provenance:

Provenance

Record: 4268
Objective:

Aims

To offer guidance on the use of chest x-rays in children

Objectives

  • To cover main indications for chest x-rays
  • To provide clarification on when to do a chest x-ray in:
    •  
      • the feverish child with no focus
      • suspected pneumonia
      • acute wheeze
      • bronchiolitis
Clinical condition: Chest x-rays
Target patient group: Children aged 0 - 16 years
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

References:

  1. NICE Guidance CG160 – Fever in under 5’s: Assessment and Initial Management (May 2013). [https://www.nice.org.uk/guidance/cg160]
  2. NICE Guidance NG51: Sepsis; Recognition, Diagnosis and Early Management (July 2016) [https://www.nice.org.uk/guidance/ng51]
  3. SIGN Guideline 153: Acute Asthma (September 2016) 
  4. NICE Guidance NG9 – Bronchiolitis in Children (June 2015) [https://www.nice.org.uk/guidance/ng9]
  5. BTS Guidelines for the management of community acquired pneumonia in children: update 2011.
  6. D Passali et al; Foreign body inhalation in children: an update; Acta Otorhinolaryngol Ital. Feb (2010); 30(1):27-32
  7. Guidelines on the Insertion of NGT and ongoing Care for Neonates, Infants and Children (May 2016)
    [detail.aspx?ID=163]

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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