Clinical scenario

A 9-month-old infant is brought to the Emergency Department by his mother with a 3-day history of coryzal symptoms and increasing difficulty breathing. Ausculation reveals widespread wheeze and crepitations, and you make a clinical diagnosis of bronchiolitis. You wonder whether a chest x-ray is indicated to confirm this diagnosis and assess its severity.

Three-part question

In (infants with bronchiolitis) is (chest x-ray) a useful investigation (to predict severity or alter management).

Search strategy

Medline 1950-March 2012 AND embase 1980- March 2012 (exp Bronchiolitis, viral/ OR exp Bronchiolitis/OR bronchiolit*.af OR RSV.af OR respiratory syncytial virus.af) AND (exp x-rays/OR xray.af OR x-ray.af OR radiograph*.af OR exp RADIOGRAPHY/ OR roentgenogram.af OR imaging.af) (Limit to: humans and (age groups all infant birth to 23 months) and English language).

Outcome

Medline returned 368 results and Embase returned 2570 results of which eight unique papers directly addressing the BET question were identified.

Comments

Several of the studies include either older children or patients with previous episodes of wheezing and therefore may not be applicable to infants with bronchiolitis. Rate of alternative diagnosis in patients with typical bronchiolitis is low and in the majority of patients presenting with bronchiolitis x-ray is unlikely to influence management. Radiological changes do not correlate strongly with clinical severity. The studies by Friis et al (1990) and Eriksson et al (1986) also suggest that x-ray changes do not reliably differentiate patients with bacterial infection from those with viral infection. Overuse of chest radiography may increase the rate of false-positive diagnosis of ‘pneumonia’ and consequently unnecessary antibiotic use.

Level of evidence

Level 2—Studies considered were neither 1 nor 3.

▶ Friis B, Eiken M, Hornsleth A, et al. Chest X-ray appearances in pneumonia and bronchiolitis. Acta Paediatr Scand 1990;79:219–25.

▶ Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatrics 2007:429–33.

▶ Mahabee-Gittens EM, Bachman D, Shapiro E, et al. Chest radiographs in the pediatric emergency department for children (less than or equal to) 18 months of age with wheezing. Clin Pediatrics 1999;395–9.

▶ Dawson K, Long A, Kennedy J, et al. The chest radiograph in acute bronchiolitis. J Pediatr Child Health 1990:209–11.

▶ Yong J, Schuh S, Rashidi R, et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonology 2009;44:122–7.

▶ Eriksson J, Nordshus T, Carlsen KH, et al. Radiological findings in children with respiratory syncyctial virus infection: relationship to clinical and bacteriological findings. Pediatr Radiol 1986;16:120–2.

▶ Farah M, Padgett L, McLario D, et al. First time wheezing in infants during respiratory syncytial virus season: chest radiograph findings. Pediatr Emerg Care 2002;18:333–6.

▶ Shaw K, Bell L, Sherman N. Outpatient assessment of infants with bronchiolitis. Am J Dis Child 1991;145:151–5.