value of the chest x-ray as a screening test pneumonia

VOLUME 67 #{149}APRIL 1981 #{149}NUMBER 4

PEDIATRICS Vol. 67 No. 4 April 1 981 447

Pediatrics

Value of the Chest X-Ray as a Screening Testfor Elective Surgery in Children

Robert A. Wood, BA, and Robert A. Hoekelman, MD

From the Department of Pediatrics, University of Rochester, School of Medicine and

Dentistry, Rochester, New York

ABSTRACT. A retrospective study was conducted toassess the value of the chest x-ray as a preoperativescreening procedure in pediatric patients. Admissions forelective surgery were compared at two hospitals, one thatrequired routine preoperative chest x-rays and one thatdid not. Our purpose was to determine the yield of the

screening chest x-ray in detecting unknown abnormalitiesand to determine whether patients who had a preopera-tive chest x-ray taken experienced fewer anesthetic orpostoperative complications than did those who did not.In all, 1,924 cases were studied; in 749 a preoperativechest film was taken. Of those 749 cases, a previouslyunsuspected abnormality was discovered in 35 (4.7%)

patients. Nine (1.2%) of these abnormalities were consid-ered to be clinically significant and three (0.4%) resultedin cancellation of surgery. No differences in anesthetic orpostoperative complications were noted between the twogroups of patients. It is recommended that the perform-ance of routine preoperative chest x-rays on apparentlyhealthy children be discontinued. Pediatrics 67:447-452,1981; chest x-ray, preoperative screening, elective sur-

gery.

Over the past ten years there has been much

debate about the value of the chest x-ray as a

screening or routine preoperative procedure.’’2

This debate has resulted from concerns about the

hazards of radiation exposure and the increasing

Received for publication June 12, 1980; accepted July 30, 1980.

Reprint requests to (R.A.H.) Department of Pediatrics, Univer-sity of Rochester, School of Medicine and Dentistry, 601 Elm-wood Aye, Box 777, Rochester, NY 14642.

PEDIATRICS (ISSN 0031 4005). Copyright © 1981 by theAmerican Academy of Pediatrics.

costs of medical care. The question still remains

whether routine preoperative chest radiography can

be justified on the basis of its yield of medical

information. Although this question has been raised

for all age groups, we have been particularly con-

cerned about its application to pediatric patients.

Three major studies of pediatric patients have

addressed this problem.’3 In 1973, Brill et al’ ana-

lyzed the findings of routine chest x-rays taken on

1,000 healthy children in a preventive health clinic

that served a low-income area of New York City.

Abnormal radiographic findings were noted in 6%

of the patients; most were minor skeletal abnor-

malities and none required treatment. In 1974, Sa-

gel et al2 reviewed the results of routine chest x-

rays taken on 521 pediatric patients as part of a

larger study of chest x-rays taken on all admissions

to Barnes Hospital in St Louis. Again, no serious

abnormalities were detected in these children. Both

Brill et al and Sagel et al concluded that routine

chest radiographs were not justified in pediatric

patients. However, in the longest study to date,

Sane et al3 reviewed the radiographic findings on

1,500 consecutive patients admitted to the Minne-

apolis Children’s Health Center for a surgical pro-

cedure. They reported that 7.5% of these patients

demonstrated at least one roentgenographic abnor-mality. Of these, 63% (4.8% of the total sample)

demonstrated a totally unsuspected significant ab-

normality. In 3.8% of the 1,500 patients, cancellation

or postponement of surgery, or a change in anes-

thetic technique resulted. On the basis of these

results, they concluded that “the routine preopera-

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448 CHEST X-RAY SCREENING FOR ELECTIVE SURGERY

tive chest roentgenographic examination is medi-

cally and economically justified and essential in

pediatric patients.”3 To evaluate this discrepancy

in study results, in 1979 we undertook a retrospec-

tive study that compared two populations of pedi-

atric patients, one in which a routine preoperative

chest x-ray was taken and one in which it was not.

This enabled us not only to analyze the x-ray find-

ings of one group, but also to compare the two

groups in terms of important variables such as

anesthetic and postoperative complications.

Although our primary goal in conducting this

study was to assess the value of preoperative chest

radiography in a “healthy” pediatric population, we

also thought it worthwhile to analyze three other

routine tests-the hematocrit, urinalysis, and tem-

perature-because these measures, along with the

chest x-ray, are used most often to assess anesthetic

risk preoperatively. The purpose of this study was

to determine: (1) the results of the x-rays and their

significance in terms of cancellation of surgery or

altered surgical management, (2) whether patients

had preoperative chest x-rays taken differed signifi-

cantly from those who did not in terms of the

frequency of occurrence of either anesthetic or post-

operative complications, and (3) the results of the

other preoperative tests (hematocrit, urinalysis, and

temperature) and their significance.

METHODS

After eliminating all cases in which a chest x-ray

was indicated on the basis of a previously recog-

nized abnormality, we reviewed the charts of allpatients under 19 years of age admitted to Strong

Memorial Hospital or Rochester General Hospital

for elective surgery during calendar year 1978. Dur-

ing that year, all 699 patients admitted to Strong

Memorial Hospital for elective surgery had a chest

x-ray taken, whereas, of the 1,225 patients admitted

to Rochester General, 50 had one taken (only when

specifically ordered by the admitting physician).

Thus, we reviewed the records of 1,924 patients.

The following information was retrieved from

each patient’s hospital record: age; sex; race; socio-

economic status (determined by census tract; home

addresses were used to categorize patients accord-

ing to one of five general socioeconomic areas);

third-party payer; diagnosis; surgical procedure;

date of admission; length of stay; number of read-

missions; results of the chest x-ray, hematocrit, and

urinalysis; maximum preoperative temperature re-

corded; anesthetic complications; postoperative

complications; and maximum postoperative term-

perature recorded. This information was sought to

enable us to study each patient’s illness, admission,

and hospital course in order to compare outcomes

for patients who did or did not have a preoperative

chest x-ray taken.

In addressing the purposes of this study, we were

able to gatxer complete data on the types of elective

surgery performed, cancellations of surgery, anes-

thetic complications, and postoperative complica-

tions, as well as the age, sex, race, and socioeco-

nomic status of the patients and the organ system

upon which their surgery was performed.

RESULTS

Of the 1,924 patients reviewed, 36% (699) were

admitted to Strong Memorial Hospital and 64%

(1,225) were admitted to Rochester General Hos-

pital. Of the total, 39% (749) had a preoperative

chest x-ray taken; 61% (1,175) did not. Sixty percent

(1,151) were boys and 40% (773) were girls; 88%

(1,702) were white, 8% (153) were black, and 4%

(69) were of another race. Ages ranged between 15

days and 19 years and were fairly evenly distributed

by year of age within the sample, although slightly

over half of the children were between 3 and 9 years

of age. Approximately 77% were insured by Blue

Cross, whereas about 10% were covered by Medi-

caid. The rest either utilized other forms of insur-

ance or were self-payers. Of the five socioeconomic

groups, 33.6% of the patients were in the highest

two categories, 56.6% were in the middle category,

and only 9.8% were in the lowest two categories.

The admissions were distributed evenly over all

months of the year, with August having the most

(196, 10.2%) and September the least (122, 6.3%).

Just over 86% of the patients remained in the

hospital for three or fewer days, 13.5% remained

from four to nine days, and 0.1% remained for ten

or more days.

The-organ systems upon which surgery was per-

formed are shown in Table 1. Of the total, 22% (432)

underwent the placement of polyethylene tubes,

either alone or in conjunction with another proce-

dure, 43% (828) of the patients, including some with

polyethylene tube placements, had a tonsillectomy,

adenoidectomy, or both.

X-Ray Findings

Of the 749 preoperative chest x-rays taken, 35

(4.7%) demonstrated some unsuspected abnormal-

ity, nine (1.2%) showed a significant unsuspected

abnormality, and three (0.4%) were used as the

reason to cancel or postpone surgery on the basis of

the roentgenographic findings. The findings that

resulted in cancellation were: (1) left lower lobe

pneumonia, (2) atelectasis in the left lower lobe

combined with some inflammatory element, and (3)

pneumonia with bilateral perihilar infiltrates. The



ARTICLES 449

35 radiographic abnormalities are listed in Table 2.

In one patient reported as having pneumonia on x-

ray, surgery was cancelled because the patient had

an upper respiratory tract infection, and the chest

x-ray was read as normal by the attending surgeon.

In another patient reported to have pneumonia on

x-ray, a repeat chest x-ray was taken on the day of

surgery and it was decided that the pneumonia had

cleared sufficiently to allow the operation to be

performed.

The frequencies of abnormal x-ray findings were

similar for different races, age groups, socioeco-

nomic groups, diagnoses, and months of admission.

Abnormal findings, however, were about two times

as frequent in boys as in girls.

TABLE 1 . Organ Systems Upon Which

gery Was PerformedEl ective Stir-

System No. %

Ear, nose, and throat 976 50.8

Urogenital 590 30.6Musculoskeletal 215 11.2

Eyes 98 5.1Other 45 2.3

Total 1,924 100.0

TABLE 2. Abnormalities Detected in 749 ScreeningPreoperative Chest X-Rays

Abnormality No. %

Lungs 16 2.1

Pneumonia* 4

Atelectasis* 2

Azygous lobet 3Bronchiectasis* 1

Consolidation* (prominence ofright pe- 1rihilar region)

Peribronchial thickening 1

Small right lower lobe infiltrate 1Increased interstitial markings 1Increased markings of right middle lobe 1Slight hilar prominence 1

Cardiovascular 14 1.9

Slight-mild cardiomegaly 3

Cardiomegaly* 1

Prominent main pulmonary artery 3

Prominent pulmonary vein 1Prominent vasculature 1

Absence of clearly defined aortic arch 1Poor definition of cardiac border 1

Curious configuration of cardiac silhou- 1ette

Cardiac silhouette upper normal limit 1Right-sided aortic archt 1

Skeletal 4 0.5Mild scoliosis 2

Pectus excavatum 1

Hypoplastic first rib 1

Other 1 0.2

Colon interposed between liver and dia- 1

phragm

* Clinically significant.

1-May be considered as anatomic variants.

Other Reasons for Cancellation of Surgery

Surgery was cancelled for 16 of the 80 patients

with a maximum preoperative temperature greater

than 99.9 F, either because of the temperature or

for another reason. The distribution of preoperative

temperatures is shown in Table 3. Surgery was

performed in 64 patients after a preoperative tern-

perature �100.0 F had been recorded. In three

cases, these temperatures were >102.4 F. Although

these patients were found in all age groups, 15.3%

were 1 year of age, and 1 1.6% were 2 years old.

Preoperative hematocrit test results in 1,918 of

the 1,924 patients studied are shown in Table 4. In

only one patient was hematocrit noted as a reason

for cancellation of surgery. This patient had a he-

matocrit of 23% in addition to a clotting disorder;

both of these findings were noted as contributing to

the cancellation. In an additional three cases, the

hematocrit was noted as low (25%, 29%, and 32%)

in the discharge summary; in each case, it was

stated that the patient would be followed for pos-

sible anemia. In two other cases, a low hernatocrit

had been previously discovered and studied. In all

other cases, however, including the eight with a

hematocrit less than 30% and the three with a

hematocrit greater than 50%, surgery was per-

formed with no mention of the finding made in the

physician’s notes.

Preoperative urinalysis testing was performed on

1,859 (96.6%) of the 1,924 patients admitted for

elective surgery. In 1,633 (87.8%) of these patients,

the urinalysis was completely normal, and in 226

(12.2%), some abnormality was discovered. Of these,

TABLE 3. Recorded Preoperative Temperatures*

Age Temperature (F)(yr)

<99.0 99.0-99.9 >99.9

<1 43 63 91 37 24 11

2 47 29 103-4 206 103 16

5-9 551 203 22

10-14 197 87 715-19 198 57 5

Total 1,279 (66.4%) 566 (29.4%) 80 (4.2%)

* n = 1,924.

TABLE 4. Preoperative Hematocrit Results*

Hematocrit No. %

23-29 13 0.730-35 452 23.6

36-40 1,134 591

41-45 273 14.246-50 43 2.2

51-60 3 0.2

* n = 1,918.




131 showed what we considered to be a significant

abnormality, as shown in Table 5. Of these patients,

14 had been admitted for a urologic procedure and

their findings on urinalysis were expected. In only

one patient did a urinalysis contribute to a cancel-

lation; in this instance, 2+ protein, 3+ blood, and

pyuria (8 to 10 WBC/high power field) were found.

Finally, reasons for cancellation of the 28 surgical

procedures are shown in Table 6. In the seven

patients in whom temperature elevation alone was

noted as the reason for cancellation, the tempera-

tures ranged from 100.4 to 102.6 F. A significant

difference in cancellation rates was demonstrated

between the two groups of patients, that is, six

(0.5%) of the patients who did not have a preoper-

ative chest x-ray taken had their operations can-

celled, compared with 22 (2.9%) of the patients who

did have x-rays taken (P < .001). However, only

three of the x-rayed group had surgery cancelled on

the basis of the x-ray results.

Anesthetic and Postoperative Complications

Anesthesia records revealed that anesthetic corn-

plications or abnormal reactions occurred in 25

(1.3%) of the patients. Most common among these

complications were laryngospasm during intubation

or extubation, coughing, and increased secretions.

None, however, was considered to be significant

TABLE 5. Significant Abnormalities Found on Preop-erative Urinalysis*

Abnormality No.

>1+ bacteria 83>10 WBC/high power field 32

>1+ occult blood or 10 RBC/high power field 18

>1+ protein 7>1+ acetone 6

�1+ glucose 2

Total 148

* n = 131; 17 of the 131 patients had more

abnormality detected on urinalysis.

than one

TABLE 6. Reason for Cancellation of Surgical Proce-dures*

Reason No.

Temperature only 7Temperature and URI or sore throat 6

URIonly 6X-ray report 3Other 6

(one each for serous otitis media and cough,chickenpox, elevated WBC count, elevated cre-atinine phosphokinase level, low hematocritand clotting disorder, and hematuria andscheduling problems)

Total 28a Abbreviation used is: URI, upper respiratory tract in-

fection.

clinically or related to the preoperative results of

the chest x-ray, the temperature, the hematocrit, or

the urinalysis.

A postoperative complication or an abnormality

was noted by the attending surgeon in the discharge

summary of 92 (4.8%) patients, as seen in Table 7.

Of the conditions listed, only fever, bleeding, nau-

sea, pneumonia, and upper respiratory tract infec-

tion can be considered postoperative complications;

of these, only fever, pneumonia, and upper respi-

ratory tract infection could in any way be detected

by using the preoperative tests we studied. Of the

22 patients in whom an elevated temperature was

noted postoperatively, 17 had a normal preopera-

tive chest x-ray. The remaining five had no preop-

erative chest x-ray. In one of the patients without

a preoperative radiograph, a postoperative chest x-

ray taken in response to a temperature of 104.4 F

demonstrated a right lower lobe pneumonia. One of

the 22 patients had had a preoperative temperature

of 101.0 F, whereas all others had had temperatures

� 99.6 F preoperatively.

The patient with pneumonia noted postopera-

tively had a normal preoperative evaluation, includ-

ing a normal chest x-ray. The patient who devel-

oped an upper respiratory tract infection following

surgery had not had a preoperative chest x-ray

taken, although one taken postoperatively was nor-

mal.

Of the 25 cases of postoperative bleeding, 23

followed tonsillectomy, adenoidectomy, or combi-

nation of the two. Thus, 2.8% of the 828 such cases

were complicated by postoperative bleeding while

the patient was still in the hospital. Of these 23

patients, 15 were returned to the operating room

for control of the bleeding and five required a

transfusion. Of the two remaining cases of postop-

erative bleeding, one followed a circumcision and

the other knee surgery.

Of the total, 21 (1.1%) patients were readmitted

to the hospital or were seen in the emergency

department with a complaint directly related to the

surgery performed. Of these, nine involved postop-

TABLE 7. Postoperative Complications and Abnor-malities Noted in Discharge Summary

Complication or Abnormality No.

Surgical cancellation explained 28Postoperative temperature elevation 22Postoperative bleeding 25Low hematocrit 3Postoperative nausea 3Abnormal urinalysis 2Right upper lobe and right lower lobe 1

pneumoniaUpper respiratory tract infection 1Other of no significance 7

Total 92



ARTICLES 451

erative bleeding-seven followed tonsifiectomy and

adenoidectomy and two followed circumcision. The

overall frequency of postoperative bleeding follow-

ing tonsillectomy and adenoidectomy, therefore,

was 30/828 or 3.6%.

Of the remaining 12 patients in whom there was

a related readmission or emergency department

visit, four were due to fever, two to upper respira-

tory tract infections, one to a wound infection, and

five to other minor problems. All of these patients

had had completely normal preoperative evalua-

tions, including chest x-rays. No patients with fever

or upper respiratory tract infection required read-

mission. In one patient, a mild postoperative fever

was noted by the attending physician in his dis-

charge summary, but the patient was discharged as

scheduled; three days later he came to the emer-

gency department with a cough and a temperature

of 102.2 F.

The distribution of maximum postoperative tern-

peratures is shown in Table 8. Of the 610 patients

in whom the temperature was >99.9 F, five had

temperatures >104.6 F. Twenty-two postoperative

fevers were noted by the physician in the discharge

summary; of these, eight were studied further: cul-

tures (throat, wound, urine, and blood) and chest x-

rays were taken, and discharge was delayed so that

these patients could be observed. The occurrence

of postoperative fever was not influenced by race,

sex, or socioeconomic status. There was some van-

ation, however, among different age groups; only

19.4% of all 1-year-old patients had a maximum

postoperative temperature >100.0 F, whereas 39.6%

of all 15- to 19-year-old patients had temperatures

>100.0 F. It was also noted that 28.7% ofall patients

who had a preoperative chest x-ray taken had a

postoperative temperature >100.0 F, compared

with 33.6% of those who did not have a preoperative

chest x-ray.

DISCUSSION

In analyzing the value of the routine preoperative

chest x-ray, one basic question must be answered:

TABLE 8. Recorded Postoperative Temperatures*

Age(yr)

Temperature (F)

<99.0 99.0-99.9 >99.9

<1 46 33 361 39 19 142 40 23 233-4 161 74 905-9 293 245 238

10-14 91 94 106

15-19 70 87 103

Total 740 (38.4%) 575 (29.9%) 610 (31.7%)

a � = 1,924.

Are the costs and possible hazards of this procedure

justified on the basis of its yield of medical infor-

mation? Similar questions should be asked of any

preoperative procedure.

In our study, 749 children received a routine

preoperative chest x-ray. A previously unsuspected

abnormality was discovered in 35 (4.7%) of these

children. Nine of the abnormalities were considered

significant and three resulted in cancellation of

surgery. When our two groups of patients were

compared, no differences in anesthetic or postop-

erative complications could be identified.

In comparison with similar studies, our data fall

between the contradictory results we have noted.’3

We detected a higher rate of roentgenographic ab-

normalities not previously known than did either

Brill or Sagel and their gu’� but a lower

rate than did Sane and his colleagues.3

The 749 chest x-rays cost $5,992 in 1978. We will

not attempt a cost-benefit analysis of this figure,

but refer interested readers to Neuhauser’stt anal-

ysis of the cost effectiveness of routine pediatric

preoperative chest x-rays based upon the data pre-

sented by Sane et al. He concludes that their claim

that such x-rays are “economically justified” is not

warranted.

Our analysis of routine preoperative measure-

ment of hematocrits showed that in only one case

(of a total of 1,918) did the result of the hematocrit

contribute to cancellation of surgery; in eight chil-

then, elective surgery was performed even though

their hematocrits were less than 30%.

Preoperative urinalysis results demonstrated

some abnormality in 226 (1 1.7%) of 1,859 patients.

In 131 of these, the abnormality was deemed sig-

nificant by our standards, yet in only one case did

results of urinalysis contribute to a decision to

cancel surgery.

Before concluding, a word about the design of

our study is indicated. The ideal study would be

prospective rather than retrospective and would

include a far larger sample population since the

incidence of operative and postoperative complica-

tions is quite small. Further, our methods of ana-

lyzing postoperative complications were not ideal;

a complete assessment of this variable would have

required contacting each patient’s surgeon and pri-

vate pediatrician to determine the true incidence of

postoperative complications. Unfortunately, we

were unable to do this.

CONCLUSIONSOn the basis of the low yield of significant infor-

mation derived from the chest x-rays we reviewed,

as well as the need to contain hospital costs and

eliminate unnecessary radiation exposure, we rec-




ommend that the practice of performing preopera-

tive chest x-rays on apparently healthy children be

discontinued. We thus agree with Brill et al’ that

preoperative chest x-rays should be performed on

an individual rather than on a routine basis.

Chest x-rays are often routinely performed on

patients admitted for nonsurgical reasons at many

hospitals and as a screening procedure in many

nonhospitalized pediatric populations, for example,

as a prerequisite for entrance to college. We also

recommend that the need for chest x-rays among

both of these groups be considered solely on an

individual basis.

We cannot recommend that routine urinalysis

and hematocrit tests be similarly eliminated, but

our results concerning these two tests do warrant

attention. Both are of relatively low cost and ex-

tremely low risk; therefore, their routine use for

screening purposes has been much less controver-

sial than the use of chest x-rays. They are also fairly

productive, as we found, in their yield of medical

information. However, we also found that the ab-

normalities detected were of little consequence vis-

#{224}-visdecisions regarding surgical procedures, since

they were seemingly ignored by attending pediatri-

cians and surgeons. The conclusions are obvious: if

these tests are of value, their results must be scru-

tinized more closely.

Finally, review of the reasons for cancellation of

elective surgical procedures reveals that a preoper-

ative temperature elevation was the most common

reason for cancellation, followed by upper respira-

tory tract infections; 21 of 28 cancellations were due

to either an elevated temperature or another finding

on the preoperative physical examination. We con-

dude, therefore, that a complete medical history

and physical examination remain the most effective

methods for screening surgical patients for potential

operative and postoperative complications.

ACKNOWLEDGMENTS

This study was supported in part by the Division ofResearch Resources, National Institutes of Health grantBRSG-RR-05403 and The Robert Wood Johnson Foun-dation General Pediatrics Academic Development Pro-gram grant 4961.

The authors wish to thank Sydney A. Sutherland andKathy Schafer for their assistance in the preparation ofthis manuscript.

ADDENDUM

In June 1979, the use of routine preoperative chest x-rays for pediatric patients at the Strong Memorial Hos-pithi was discontinued. This decision was not based uponthe results of the study reported here.

REFERENCES

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1981;67;447PediatricsRobert A. Wood and Robert A. Hoekelman

Value of the Chest X-Ray as a Screening Test for Elective Surgery in Children

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