Diagnostic Imaging Pathways - Chest X-Ray (Pre-Operative)

Pathway

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Teaching Points

Teaching Points

Take Home Point

• Routine CXR is not indicated in the pre-anaesthetic assessment of asymptomatic patients 1-6
• Preoperative CXR for anaesthetic evaluation should be based on history and clinical examination, and should be reserved for patients with symptoms of acute illness requiring investigation 1, 2
• CXR may be indicated for surgical planning or oncology staging in some cases 1-4

About Preoperative Chest Radiography (CXR)

• History and examination have been shown to predict most clinically significant abnormalities that would be detected on CXR 7
• Disadvantages of extensive routine preoperative testing include 8
  • patient discomfort
  • unnecessary waiting times for some procedures
  • unnecessary direct costs and potential for unnecessary subsequent tests related to false-positive abnormal findings
• In asymptomatic patients, the yield of CXR is low 9 and abnormal findings rarely change management 7, 10-13
• Even in older patients, most detected abnormalities reflect chronic disorders and do not impact on anaesthetic management or perioperative outcome 3
• Routine CXR is a poor predictor of post-operative pulmonary complications 1, 3, 14
• A randomized, single-blind, prospective, controlled pilot study showed that there was no increase in the perioperative adverse events as a result of no preoperative testing 15

References

References

Date of literature search: March 2018

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

1. McComb BL, Chung JH, Crabtree TD, Heitkamp DE, Iannettoni MD, Jokerst C, et al. ACR appropriateness criteria(R) routine chest radiography J Thorac Imaging. 2016;31(2):W13-5. (Guideline). View the reference
2. Canadian Anesthesiologists' Society. Anesthesiology. Five things physicians and patients should question: Choosing Wisely Canada; 2017 [updated June 2017]. (Guideline). View the reference
3. Australian and New Zealand College of Anaesthetists. Australian and New Zealand college of anaesthetists: tests, treatments and procedures clinicians and consumers should question 2017 [updated Jan 2017]. (Guideline). View the reference
4. Merchant R, Chartrand D, Dain S, Dobson G, Kurrek MM, Lagace A, et al. Guidelines to the practice of anesthesia - revised edition 2016. Can J Anaesth. 2016;63(1):86-112. (Guideline). View the reference
5. Smith I, Al-Mohammad A, Clark L, Crook M, Dhesi J, Howard L, et al. Preoperative tests (update); routine preoperative tests for elective surgery. National Institute for Health and Care Excellence; 2016. (Guideline). View the reference
6. Practice advisory for preanesthesia evaluation. An updated report by the American society of anesthesiologists task force on preanesthesia evaluation. Anesthesiology. 2012;116(3):522-38. (Guideline). View the reference
7. Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth. 1993;40(11):1022-7. (Level I evidence). View the reference
8. Garcia-Miguel FJ, Serrano-Aguilar PG, Lopez-Bastida J. Preoperative assessment. Lancet. 2003;362(9397):1749-57. (Review article). View the reference
9. Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth. 2005;52(6):568-74. (Level I evidence). View the reference
10. den Harder AM, de Heer LM, de Jong PA, Suyker WJ, Leiner T, Budde RPJ. Frequency of abnormal findings on routine chest radiography before cardiac surgery. J Thorac Cardiovasc Surg. 2018 (Level III evidence). View the reference
11. Mikhael A, Patell R, Tabet M, Bena J, Berber E, Nasr C. Chest x-ray prior to thyroidectomy: is it really needed? World J Surg. 2017 (Level III evidence). View the reference
12. Loggers SAI, Giannakopoulos GF, Vandewalle E, Erwteman M, Berger F, Zuidema WP. Preoperative chest radiographs in hip fracture patients: is there any additional value? European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2017 (Level III evidence). View the reference
13. Ali IS, Khan M, Khan MA. Routine preoperative chest x-ray and its impact on decision making in patients undergoing elective surgical procedures. Journal of Ayub Medical College, Abbottabad : JAMC. 2013;25(1-2):23-5. (Level III evidence). View the reference
14. Boghosian SG, Mooradian AD. Usefulness of routine preoperative chest roentgenograms in elderly patients. J Am Geriatr Soc. 1987;35(2):142-6. (Level III evidence). View the reference
15. Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT. Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009;108(2):467-75. (Level II evidence). View the reference

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