F
F. Thoracic system

CLINICAL/DIAGNOSTIC

PROBLEM

INVESTIGATION

RECOMMENDATION

(GRADE) 

COMMENT

DOSE

Non-specific chest pain

CXR

Not indicated initially (C)

Conditions such as Tietze's disease show no abnormality on CXR.  Main purpose is reassurance.

I
 
Minor chest trauma CXR Indicated only in specific circumstances (C) Showing a rib fracture does not alter management. I
 
Pre-employment or screening medicals CXR Indicated only in specific circumstances (B) Not justified except in a few high-risk categories (e.g. at-risk immigrants with no recent CXR).  Some have to be done for occupational (e.g. divers) or emigration purposes (UK category 2). I
 
Routine pre-operative CXR CXR Not Indicated (A) Routine pre-operative CXR is not indicated in patients aged <60 years undergoing non-cardiothoracic surgery. The yield of abnormalities increases in patients >60. However, if patients without known cardio-respiratory disease are excluded, the yield is still low. I
 
Upper respiratory tract infection CXR Not Indicated (C) There is no documented evidence of the effect of CXR on the management or outcome of upper respiratory tract infection. I
 
Acute exacerbation of asthma CXR Indicated only in specific circumstances (B) Patients presenting with asthma but without localising signs in the chest, pyrexia, or leucocytosis do not require CXR, except when the asthma is life-threatening or fails to respond to treatment adequately. I
 
Acute exacerbation of COPD CXR Indicated only in specific circumstances (B) Patients presenting with COPD but without localising signs in the chest, pyrexia, or leucocytosis do not require CXR, except when the condition is life-threatening or fails to respond to treatment adequately. I
 
Pneumonia

 

(For children see section M)

 CXR Indicated (C) The majority of patients with community-acquired pneumonia will show radiological resolution at four weeks, but this may be prolonged in the elderly, smokers, and those with chronic airway disease.  Further CXR after resolution in asymptomatic patients is not indicated. I
 
Pneumonia: follow-up CXR Indicated only in specific circumstances (B) CXR need not be repeated before hospital discharge in those who have made a satisfactory clinical recovery from community-acquired pneumonia.  CXR should be arranged after about six weeks for all patients who have persistent symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and patients > 50 years), whether or not they are admitted to hospital. I
 
Pleural effusion suspected CXR Indicated (C) CXR may detect small quantities of pleural fluid I
US Indicated (B) US may be used to confirm the presence of pleural fluid, characterise it, detect metastases, and guide thoracentesis. 0
CT Indicated only in specific circumstances (B) CT with IV contrast may help in the detection and characterisation of pleural fluid. III

 
 
Haemoptysis CXR Indicated (B) All patients presenting with haemoptysis should have a CXR. If this is normal and the haemoptysis was significant and occurred out of context of a concurrent chest infection, referral for further investigation should be considered. I
CT Not indicated initially (B) CT should be used in conjunction with bronchoscopy to investigate the majority of patients with haemoptysis. CT may detect malignancies not identified on CXR or bronchoscopy, but is insensitive in detecting mucosal and submucosal disease. III
 
ITU/HDU patient CXR Indicated (B) A CXR is most helpful when there has been a change in symptoms or insertion or removal of a device. The value of the routine daily CXR is being increasingly questioned. CT is a useful adjunct to CXR for problem-solving in critically ill patients. I
 
Occult lung disease CT Specialised investigation (B) There is evidence to indicate that high resolution CT (HRCT) may be histospecific; valuable information about disease reversibility and prognosis may be gleaned from HRCT. III
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