CXR in Pediatric Respiratory Illness

Reduction in use of CXR for Children with Asthma, Bronchiolitis, and Croup

Respiratory illnesses are among the top ten diagnoses for which children visit an emergency department and asthma, bronchiolitis and croup are the most common pediatric respiratory illnesses. Medical evidence suggests that CXRs are frequently used by emergency providers in children presenting for these conditions, yet CXRs rarely reveal information that leads to changes in management. Several studies also reveal significant variation in CXR use in asthma, bronchiolitis and croup in both children’s hospital and general emergency departments with higher utilization rates in the latter. Guidelines for CXR use are now available through the American Academy of Pediatrics and the medical literature for these conditions. This approach has been endorsed as a Choosing Wisely recommendation by the American Academy of Pediatrics Section on Emergency Medicine and the Canadian Association of Emergency Physicians. The Collaborative has adopted a utilization quality measure to reduce CXR use in children < 18 years with asthma, bronchiolitis, and croup.

MEDIC Low Value CXR Guidelines Toolkit

Educational Materials for National & International CXR Guidelines

Key References

  • American Academy of Pediatrics – Section on Emergency Medicine and the Canadian Association of Emergency Physicians. Five Things Physicians and Patients Should Questions. Choosing Wisely. Dec 2022.
  • American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93.
  • Chamberlain JM, et al. Practice pattern variation in the care of children with acute asthma. Academic Emergency Medicine Journal. Feb 2016; 23(2).
  • Chao JH, et al. Predictors of airspace disease on CXR in ED patients with clinical bronchiolitis: A systematic review and meta-analysis. Academic Emergency Medicine Journal. Oct 2016;23(10).
  • Florin TA, et al. Pneumonia in children presenting to the emergency department with asthma exacerbation. JAMA Pediatr. 2016 Aug 1;170(8):803-5.
  • Florin TA, et al. Viral bronchiolitis. Lancet. 2017 Jan 14;389(10065):211-224.
  • Hanna J, et al. Epidemiological analysis of croup in the emergency department using two national datasets. Int J Pediatr Otorhinolaryngol. 2019 Nov;126:109641.
  • Mansbach JM, et al. Bronchiolitis in US emergency departments 1992 to 2000: epidemiology and practice variation. Pediatr Emerg Care. 2005 Apr;21(4):242-7.
  • Mullan PC, Levasseur KA, Bajaj L, Nypaver M, Chamberlain JM, Thull-Freedman J, Ostrow O, Jain S.  Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five opportunities to improve value.  Annals of Emergency Medicine, Accepted January 4, 2024, in Press. 
  • National Asthma Education and Prevention Program. Expert panel report 3 (EPR 3): Guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol2007;120:S94-S138. This document can also be found here
  • Petrocheilou A, et al. Viral Croup: diagnosis and a treatment algorithm. Pediatr Pulm. 2014;49(5).
  • Ralston RL, et al. Clinical Practice Guideline: The diagnosis, management and prevention of bronchiolitis. From the American Academy of Pediatrics. Pediatrics. November 2014; 134 (5).
  • Shah SN, et al. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471.
  • Shuh S, et al. Evaluation of the utility of radiography in acute bronchiolitis. Pediatr. 2007; 150:429-433
  • Society of Hospital Medicine: Pediatric Hospital Medicine. Choosing Wisely. 2013 February.
  • Trottier ED, Chan K, Allain D, Chauvin-Kimoff L. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438-439.
  • Zahran HS, et al. Vital Signs: Asthma in Children – United States, 2001-2016. MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):149-155.