Routine chest X-rays out for bronchiolitis and asthma

Chest X-rays in children with bronchiolitis or asthma are unlikely to inform management and should therefore be avoided, according to the RACP’s Paediatrics and Child Health Division.

In their top five ‘Do-not-do’ recommendations, the Division said chest X-rays did not discriminate well between bronchiolitis and other lower respiratory tract infections.

“It is estimated that 133 children with typical bronchiolitis would have to undergo radiography to identify one radiograph that is suggestive of an alternate diagnosis,” the statement said.

President of the Division Dr Sarah Dalton told the limbic that bronchiolitis was typically over-investigated and over-treated.

“In some instances it is indicated to do a chest X-ray, for example to eliminate pneumonia or an air leak but in so many cases X-rays are not actually showing us that differential diagnosis. Very often we are doing X-rays and not changing management.”

She said one of the dangers lay in the number of X-rays young children with recurrent presentations might have.

“If they end up with six X-rays under the age of two years, we are exposing them to harm of radiation and not getting much positive value and impact from doing the test.”

Dr Dalton said implementing the recommendations relied on discussion with parents.

“We can’t do it alone. We have to do it in discussions with our patients and their families as it’s a lot about their expectations. It’s so much easier and quicker to do the X-ray than have the conversation about why it is not required.”

The recommendations, from the RACP’s EVOLVE program and the Choosing Wisely campaign, advised that bronchodilators including salbutamol do not improve oxygen saturation or reduce hospital admissions, length of stay or duration of illness.

It also advised there was no evidence for systemic or inhaled corticosteroids in children with bronchiolitis.

“What we can do is make sure they don’t have severe respiratory distress, make sure they don’t have hypoxaemia and make sure they aren’t dehydrated. If they get breathless, they can’t feed and they can get very dehydrated.”

“A lot of what we do is watch them feed or provide nasogastric or IV fluids to support them. That would be the most common therapeutic approach that we have.”

The Division also recommended against routine X-rays for children with asthma.

“There is extensive evidence that the majority of X-rays ordered for children admitted for asthma and wheezing disorders do not provide clinically relevant information and therefore do not contribute to their diagnosis and management,” the statement said.

“It’s very challenging for doctors to walk the line, between not missing something and not testing too much,” Dr Dalton said.

She added that work was underway to embed the recommendations in technological prompts within hospital and organisation-wide systems.

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