• Aquino SL, Khan A, Batra PV, Gurney JW, Haramati LB, MacMahon H, Mohammed TL, Rozenshtein A, Vydareny KH, Washington L, Winer-Muram HT, Woodard PK, Kaiser L, Raoof S, Expert Panel on Thoracic Imaging. Routine chest radiograph. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 6 p. [21 references]

This is the current release of the guideline.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Cardiopulmonary, respiratory or other condition for which a routine chest radiograph is recommended.

Note: This guideline concerns the daily routine radiograph only and does not include postprocedural or postsurgical radiographs.

Evaluation

Cardiology
Emergency Medicine
Internal Medicine
Pulmonary Medicine
Radiology

Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management

To evaluate the appropriateness of routine chest radiograph for patient monitoring, evaluation after specific procedures, and documentation of the presence or course of a disease

Patients with a cardiopulmonary, respiratory or other condition for which a routine chest radiograph is recommended

Routine x-ray, chest, portable

• Initial admission
• Immediately following catheter or tube insertion
• Follow-up for specific indications
• Subsequent follow-up for catheter or tube position

Utility of routine chest radiograph in detecting significant abnormalities affecting patient management

Searches of Electronic Databases

The guideline developer performed literature searches of peer-reviewed medical journals and the major applicable articles were identified and collected.

The total number of source documents identified as the result of the literature search is not known.

Weighting According to a Rating Scheme (Scheme Not Given)

Not stated

Systematic Review with Evidence Tables

One or two topic leaders within a panel assume the responsibility of developing an evidence table for each clinical condition, based on analysis of the current literature. These tables serve as a basis for developing a narrative specific to each clinical condition.

Expert Consensus (Delphi)

Since data available from existing scientific studies are usually insufficient for meta-analysis, broad-based consensus techniques are needed for reaching agreement in the formulation of the appropriateness criteria. The American College of Radiology (ACR) Appropriateness Criteria panels use a modified Delphi technique to arrive at consensus. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. These questionnaires are distributed to the participants along with the evidence table and narrative as developed by the topic leader(s). Questionnaires are completed by participants in their own professional setting without influence of the other members. Voting is conducted using a scoring system from 1-9, indicating the least to the most appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted and opinions are unified to the highest degree possible. Eighty percent agreement is considered a consensus. This modified Delphi technique enables individual, unbiased expression, is economical, easy to understand, and relatively simple to conduct.

If consensus cannot be reached by the Delphi technique, the panel is convened and group consensus techniques are utilized. The strengths and weaknesses of each test or procedure are discussed and consensus reached whenever possible. If "No consensus" appears in the rating column, reasons for this decision are added to the comment sections.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

ACR Appropriateness Criteria®

Clinical Condition: Routine Chest Radiograph

Variant 1: Monitoring stable patient.

Variant 2: Respiratory failure. Patient receiving mechanical ventilation.

Variant 3: Compromised respiratory function. Patient with endotracheal tubes.

Variant 4: Central venous pressure catheter (CVP) insertion.

Variant 5: Cardiopulmonary compromise. Swan-Ganz catheter insertion.

Variant 6: Potential cardiopulmonary compromise. Nasogastric (NG) tube insertion.

Variant 7: Respiratory compromise. Chest tube insertion.

Summary of Literature Review

Portable Radiographs in the Intensive Care Unit (ICU) Setting

Portable radiographs can be categorized as: 1) daily or routine radiographs for patient monitoring; 2) radiographs obtained after specific procedures; and 3) radiographs documenting the presence or course of disease.

Routine daily portable radiographs are indicated for patients with acute cardiopulmonary problems. In stable patients admitted for cardiac monitoring, or in stable patients admitted for extrathoracic disease only, an initial admission radiograph is recommended, with follow-up radiographs obtained only for specific clinical indications.

Endotracheal Tubes

Very few malpositioned tubes are detected by physical examination. Routine radiographs immediately postintubation are indicated to insure proper positioning.

Central Venous Pressure (CPV) Catheters

A chest radiograph (CXR) after insertion of a CVP catheter is recommended to demonstrate proper placement and detect any complications. Beyond the initial insertion, follow-up radiographs have a low yield for revealing complications. Follow-up radiographs are suggested only when complications are suspected clinically.

Swan-Ganz Catheters

Portable radiography is suggested after catheter insertion. Once pneumothorax has been excluded and proper positioning has been assured, follow-up radiographs are not required except for specific clinical indications.

Nasogastric Tubes

Based on limited evidence, small-bore feeding tubes may, in a small but significant number of patients, be inadvertently placed in the lungs. This error is not always detected clinically and may lead to injection of feeding material into the lung, or tube penetration of the pleura, with subsequent pneumothorax. A CXR is warranted after initial nasogastric tube insertion and before the first feeding. Beyond the initial radiograph, follow-up radiographs are not required for management of stable tubes.

Chest Tubes

After insertion of a chest tube, a CXR is recommended to show the position of the tube, any success in drainage, and possible complications from insertion. Beyond this point, evaluation of tube position and function is warranted based on management of the pleural space and clinical indications.

Algorithms were not developed from criteria guidelines.

The recommendations are based on analysis of the current literature and expert panel consensus.

Appropriate use of routine chest radiograph for patient monitoring, evaluation after specific procedures, and documentation of the presence or course of a disease

Not stated

An American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Aquino SL, Khan A, Batra PV, Gurney JW, Haramati LB, MacMahon H, Mohammed TL, Rozenshtein A, Vydareny KH, Washington L, Winer-Muram HT, Woodard PK, Kaiser L, Raoof S, Expert Panel on Thoracic Imaging. Routine chest radiograph. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 6 p. [21 references]

Not applicable: The guideline was not adapted from another source.

2006

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Thoracic Imaging

Panel Members: Suzanne L. Aquino, MD; Arfa Khan, MD; Poonam V. Batra MD; Jud W. Gurney, MD; Linda B. Haramati, MD; Heber MacMahon, MD; Tan-Lucien H. Mohammed, MD; Anna Rozenshtein, MD; Kay H.Vydareny, MD; Lacey Washington, MD; Helen T. Winer-Muram, MD; Pamela K. Woodard, MD; Larry Kaiser, MD; Suhail Raoof, MBBS

Not stated

This is the current release of the guideline.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This NGC summary was completed by ECRI Institute on May 10, 2007.