Evaluation of first time wheezing episodes: When is a chest radiograph indicated?

Five to ten percent of all children will have an illness accompanied by wheezing. Despite the recommendation by many texts that evaluation of first time wheezing include a chest x-ray, its role in diagnostic evaluation remains controversial. Purpose: To evaluate the use of and need for chest radiographs (CXR) in the workup of pediatric patients with first time wheezing (FTW) episodes. Methods: 298 episodes of FTW were identified by chart review of 1,984 patients seen in the Emergency Department at Children's Hospital in 1994 with the diagnoses of asthma, RAD, bronchiolitis, pneumonia, congenital heart disease, congestive heart failure, and foreign body aspiration. Clinical findings in FTW were compared in patients receiving a CXR (121, 41%) and those who did not (177, 59%). Comparisons were made between patients with a clinically significant CXR (CXR-pos) (29, 24%) and those without (92, 76%). CXR-pos was defined as a CXR result which altered patient management. Results: Patients receiving CXR differed from those who did not by being of a greater age (39 vs. 20 mo. p<.01), having lower pulse oximetry (89.7 vs. 92.7% p<.01), being less likely to have a family history of asthma (47.5 vs. 63.2% p<.01), or history of atopy (40.6 vs. 59.4% p<.01). Those with localized wheezes (59.4 vs. 40.6% p<.01), localized rales (59.3 vs. 40.7% p<.01) and localized decreased breath sounds (59.3 vs. 40.7% p=.01) were also more likely to have a CXR. Among patients receiving CXR the only clinical parameters associated with CXR-pos were elevated temperature (37.9 vs 37.5°C, P=.04), absence of family history of asthma (72.6 vs 27.4%, p<.01), and the presence of localized wheezes (76.0 vs 24.0%, p=.02), or localized rales (76.0 vs 24.0%, p<.01). Conclusion: Despite current recommendations, clinicians do not obtain a CXR in all patients with first time wheezing episodes. Clinicians use several clinical parameters to determine which patients require a CXR. However, only elevated temperature, absence of a family history of asthma and localized wheezes or rales were associated with CXR-pos.