Chest Radiography Should Be Requested Only on Admission Based on Clinical Grounds

Zvi Shimoni, MD; Michal Rosenberg, MD; Leeor Amit, MD; Paul Froom, MD


South Med J. 2020;113(1):20-22. 

In This Article

Abstract and Introduction


Objectives: To determine the clinical utility and adverse consequences of routine admission chest x-ray (CXR) findings in patients with and without respiratory complaints and/or an abnormal chest examination.

Methods: In this prospective cohort study in an internal medicine department, we selected 273 patients and determined outcomes by chart review and physician interviews. The patients were divided into those with and without respiratory tract symptoms and/or findings on chest examination. The outcome variables were appropriate or inappropriate changes in treatment based on CXR findings.

Results: Of the 35 patients with respiratory tract symptoms/signs, 7 (20%) had a change in therapy based on CXR findings, which was effective in 5 of them. In the other 238 patients, an unexpected pleural empyema was detected in a hypotensive dialysis patient (0.4%, 95% confidence interval 0–2.3). Besides costs and radiation exposure, major adverse effects included two patients (0.8%, 95% confidence interval 0.1–3.0) with a false-positive test result that resulted in inappropriate hospitalizations and antibiotic therapy. In patients without respiratory tract symptoms or findings on physical examination, the clinical benefits and major adverse consequences were uncommon.

Conclusions: Admission CXRs in patients without respiratory tract symptoms or findings are unwarranted except perhaps in older adult patients with comorbidities and an unclear admitting diagnosis.


An expert panel concluded that the available evidence does not support the broad performance of routine chest radiography (CXR) because findings uncommonly add clinically significant information not predicted by a reliable history and physical examination[1] and that anticipated value should consider adverse effects. The admission CXR only occasionally has clinical utility[1–3] in patients without respiratory tract symptoms or signs, leading to recommendations that they be limited to those with clinical findings of cardiopulmonary disease and to high-risk patients variously defined.[2,3] Nevertheless, it may be prudent to continue such testing if adverse consequences are equally uncommon.

In the present study, we asked physicians whether findings on CXRs influenced treatment decisions and then reviewed the charts to determine the frequency of clinical utility and adverse consequences.