When should a chest x-ray be used to evaluate acute-onset productive cough for adults?

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When should a chest x-ray be used to evaluate acute-onset productive cough for adults?

J Fam Pract. 2005 December;54(12):1081-1083

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References

1. Diehr P, Wood RW, Bushyhead J, Krueger L, Wolcott B, Tompkins RK. Prediction of pneumonia in outpatients with acute cough-a statistical approach. J Chronic Dis 1984;37:215-225.

2. Emerman CL, Dawson N, Speroff T, Siciliano C, Effron D, Rashad F, et al. Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients. Ann Emerg Med 1991;20:1215-1219.

3. Cypress BK. Patients’ reasons for visiting physicians: National Ambulatory Medical Care Survey: United States, 1977-1978. Vital Health Stat 13 1981;56:1-134.

4. Heckerling PS, Tape TG, Wigton RS, et al. Clinical prediction rule for pulmonary infiltrates. Ann Intern Med 1990;113:664-670.

5. Gennis P, Gallagher J, Falvo C, Baker S, Than W. Clinical criteria for the detection of pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency department. J Emerg Med 1989;7:263-268.

6. Singal BM, Hedges JR, Radack KL. Decision rules and clinical prediction of pneumonia: evaluation of lowyield criteria. Ann Emerg Med 1989;18:13-20.

7. Bushyhead JB, Wood RW, Tompkins RK, Wolcott BW, Diehr P. The effect of chest radiographs on the management and clinical course of patients with acute cough. Med Care 1983;1:661-673.

8. Macfarlane J, Holmes W, Gard P, et al. Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community. Thorax 2001;56:109-114.

9. Bartlett JG, Dowell SF, Mandell LA, File TM, Jr, Musher DM, Fine MJ. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis 2000;31:347-382.

10. Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia.Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001;163:1730-1754.

11. Mandel LJ, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. The Canadian Community-Acquired Pneumonia Working Group. Clin Infect Dis 2000;31:383-421.

12. Heffelfinger JD, Dowell SF, Jorgensen JH, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the drug-resistant streptococcus pneumoniae therapeutic working group. Arch Intern Med 2000;160:1399-1408.

13. British Thoracic Society Standards of Care Committee BTS guidelines for the management of communityacquired pneumonia in adults. Thorax 2001;56:IV1-164.

14. European Respiratory Society Task Force Report. Guidelines for management of adult communityacquired lower respiratory tract infections. Eur Respir J 1998;11:986-991.

FIGURE
When to order chest x-ray?

Clinical decision rules detected 59% of pneumonias, vs just 33% with physician judgment.

TABLE 1
Signs and symptoms significant for pneumonia

FACTOR	SCORE
Rhinorrhea	–2
Sore throat	–1
Night sweats	1
Myalgias	1
All-day sputum production	1
Respiratory rate >25/min	2
Temperature ≥100° F	2
Adapted from Diehr et al, J Chronic Dis 1984.¹

TABLE 2
Distribution of point scores for pneumonia and non-pneumonia groups

POINT SCORE	NUMBER WITH PNEUMONIA	NUMBER WITHOUT PNEUMONIA	PERCENTAGE WITH PNEUMONIA	CUMULATIVE SENSITIVITY	CUMULATIVE SPECIFICITY
–3	0	140	0	100	8
–2	4	552	0.7	91	40
–1	8	504	1.6	74	70
0	7	316	2.2	59	88
1	12	124	808	33	96
2	6	52	10.3	20	99
3	4	12	25.0	11	99
4	3	8	27.3	4	100
5	1	4	20.0	2	100
6	1	0	100.0	0	100
Total	46	1712	2.6
Adapted from Diehr et al, J Chronic Dis 1984.¹

Recommendations from others

The Infectious Disease Society of America, the American Thoracic Society, the Canadian Infectious Disease Society and the Canadian Thoracic Society, and the Centers for Disease Control and Prevention all recommend a chest x-ray for patients for whom signs and symptoms suggest a pneumonia, but they do not give any guidance as to which signs and symptoms are significant.^9-12 The British Thoracic Society does not recommend radiography for patients with suspected pneumonia among outpatients.¹³ The European Respiratory Society only recommends a chest x-ray for those patients with failure of first-time empirical therapy or focal chest signs; a chest x-ray may also be indicated for those who are aged ≥65 years, are institutionalized, are alcoholics, have possibly aspirated, have been hospitalized within the previous year for pneumonia, or have significant comorbidities.¹⁴