Diagnostic Imaging Pathways - Chest X-Ray (Pre-Operative)
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Population Covered By The Guidance
This pathway provides guidance on the appropriate use of preoperative chest radiographs in adult patients.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Teaching Points
Teaching Points
- A preoperative CXR should be considered if the patient has, or is at risk of, cardiac/pulmonary disease or if a malignancy is suspected, after conducting a history and physical examination
- In addition, some surgeries may require a preoperative CXR. These include
- All abdominal, thoracic and cardiac surgeries and some oesophageal surgeries
- Thyroidectomy and other head and neck surgeries
- Neurosurgeries
- Lymph node surgeries
cxr
Routine Pre-operative Chest Radiograph
- Preoperative chest radiographs are usually requested to complete investigations in patients to detect asymptomatic abnormalities and to get some baseline imaging as well as for medico legal purposes 1,2
- Drawbacks to the extensive use of routine preoperative testing are 2
- patient discomfort
- unnecessary waiting times for some procedures
- unnecessary direct costs and potential for unnecessary subsequent tests related to false-positive abnormal findings
- Over the past years there have been several studies that show routine chest radiographs to be useful only in AT RISK patients
- An association between preoperative screening radiographs and decrease in morbidity or mortality could not be established in the systematic review by Joo et al 10
- Routine chest radiographs should not be performed for any patient without risk factors as there is good evidence supporting the low prevalence of chest radiograph abnormalities in this group 10
- In a meta-analysis that included 21 reports, only 1.3% of films were unexpectedly abnormal; i.e. the abnormalities would not otherwise have been detected. These findings caused modification of management in only 0.1% 9
- A recent 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 12
- Another prospective multicentre study indicated that in healthy, female, < 61 year-old patients, due for standard surgery, the probability of a useful preoperative chest radiograph ranges from 0.2% to 3.5%. The probability increases in male or elderly patients, or in the presence of coexisting respiratory diseases, or in ASA (American Society of Anesthesiologists’ physical status classification) classes >2 11
- The pioneering study of the Swedish Council on Technology Assessment in Health Care from 1989 quantified the high degree of inappropriate use of preoperative tests for elective surgery. In a national survey of anaesthetists, 60 agreed that there was no scientific evidence to support widespread use of chest radiography in asymptomatic patients 4
risk
Indications For Pre-operative Chest Radiograph
- The Canadian Anaesthesiologists’ Society suggests only performing preoperative chest radiography if a patient has, or is at risk of, cardiac / pulmonary disease or if a malignancy (with or without metastasis) is suspected, after conducting a history and physical examination 3
- Other indications include (but are not limited to)
- Immigrants from developing countries without a chest radiograph in the previous 12 months 5,6
- Long term smokers 5,7
- When there is any reason to doubt the reliability of the clinical examination or medical history (e.g. senility, intoxication, dementia, or linguistic or cultural barriers) 9
- Some types of surgery may require the need for a preoperative chest radiograph (i.e. non-generic preoperative testing). These include 8
- All abdominal, thoracic and cardiac surgeries and some oesophageal surgeries
- Thyroidectomy and other head and neck surgeries
- Neurosurgeries (due to prolonged anaesthesia and the need for intensive care after surgery)
- Lymph node surgeries
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Bouillot JL et al. Are routine preoperative chest radiographs useful in general surgery? A prospective, multicentre study in 3959 patients. EAST practice management guidelines for trauma. Eur J Surg. 1996;162(8):597-604. (Level II evidence)
- Garca-Miguel F J , Serrano-Aguilar PG, Zlopez-Bastida J. Preoperative assessment. Lancet. 2003;362:1749-57. (Review article)
- Merchant R , Bosenberg C, Brown K, Chartrand D, Dain S, Dobson J et al. Guidelines to the practice of anesthesia. J Can Anesth. 2010;57:58-87. (Level I evidence)
- Harden CL et al. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;69(18):1772-80. (Level I evidence)
- Diaz JJ Jr, Cullinane DC, Altman DT, Bokhari F, Cheng JS, Como J et al. Practice management guidelines for the screening of thoracolumbar spine fracture. J Trauma. 2007;63(3):709-18. (Level II evidence)
- Holmes JF, Panacek EA, Miller PQ, Lapidis AD, Mower WR. Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients. J Emerg Med. 2003;24(1):1-7. (Level II evidence)
- Calendine CL, Fajman WA , Hanna SL, Tigges S. Is there need for thoracic spine radiographs following a negative chest CT in trauma patients? Emerg Radiol. 2002;9(5):254-6. (Level III evidence)
- Reinus WR, Strome G, Zwemer F. Use of lumbosacral spine radiographs in a level II emergency department. AJR Am J Roentgenol. 1998;170:443-7. (Level III evidence)
- 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
- 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
- Silvestri L, Maffessanti M, Gregori D, et al. Usefulness of routine pre- operative chest radiography for anaesthetic management: a prospective multicentre pilot study. Eur J Anaesthesiol. 1999;16:749-60. (Level II evidence). View the reference
- Chung F, Yuan H, Yin L, Vairavanathan S, Wong D. Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009;108(2):467-75. (Level I evidence). View the reference
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Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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