Value of Preoperative Chest X-ray Examinations in Children

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Value of Preoperative

Chest

X-ray

Examinations

in

Children

Shashikant M. Sane, M.D., Robert A. Worsing, Jr., M.D., Cornelius W. Wiens, M.D.,

and Rajiv K. Sharma

From the Department of Radiology, Minneapolis Children’s Health Center

ABSTRACT. To assess the value of routine preoperative chest x-ray films in pediatric patients, a prospective study of

1,500 patients, ages newborn to 19 years, was undertaken. Of all the patients, 7.5% demonstrated at least one roentgeno-graphic abnormality, with 4.7% of the patients demon-strating a totally unsuspected significant roentgenographic anomaly. In 3.8% of the patients, surgery was either post-poned or cancelled or the anesthetic technique was altered

as a result of the roentgenographic finding. It is believed that

the routine preoperative chest film is justified if the film is evaluated before surgery and the results clinically followed up. Pediatrics 60:669-672, 1977, CHEST X-RAY EXAMINATIONS,

PREOPERATIVE PROCEDURES.

the chest roentgenograph.” At Minneapolis Chil-dren’s Health Center, all children undergoing general anesthesia receive a routine preoperative roentgenographic examination of the chest. In order to evaluate whether these examinations are justified or not, we undertook a prospective study of preoperative chest roentgenographic examina-tions on 1,500 consecutive patients from Novem-ber 1974 through June 1975. The purpose of this article is to report the findings of that study.

METHODS AND SUBJECTS

In recent years, there has been an increasing

feeling that “routine” chest roentgenography in “healthy” patients is not justified in terms of the yield of medical information, patient cost, and resultant radiation exposure. ‘ This feeling has

been specifically emphasized in pediatric pa-tients. In 1973, Brill et al. reviewed chest roent-genographs of 1,000 healthy children in a

preven-.live pediatric clinic in a low-income area in New York City. Only 6% of the patients had roentgen-ographically reportable findings, most of which were minor skeletal anomalies and none of which required treatment.’#{176} In November 1974, Sagel et al. reviewed the efficacy of routine chest

roent-genographs on patients admitted to Barnes

Hospital in St. Louis. In the 521 patients under the age of 20 on whom chest roentgenography was performed merely because the patient was admitted to the hospital or scheduled for an operative procedure, no cases were detected in which a serious abnormality was demonstrable on

One thousand five hundred consecutive pre-operative chest roentgenograms in frontal and lateral views were obtained on patients, newborn to 19 years of age, between November 1974 and

J

une 1975. The roentgenograms were interpreted

by two radiologists. All “abnormal” findings were tabulated at the time the roentgenograms were interpreted. If the child was scheduled to undergo a thoracic surgical procedure, the abnormal find-ings pertaining to that disease entity were not included as abnormal findings in this study. Following the completion of the study, the patient charts were reviewed for the following information:

1. Was the roentgenographic anomaly known, suspected, or an entirely new finding?

2. Did the roentgenographic findings cause

Received August 11, 1976; revision accepted for publication March 2, 1977.

ADDRESS FOR REPRINTS: (S.M.S.) Department of Radiol-ogy, Minneapolis Children’s Health Center, 2525 Chicago

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670 CHEST X.RAY EXAMINATIONS

TABLE I

SIcNIFIc.rr ABNORMALITIES ON PREOPERATIVE CHEST

ROENTGENOGRAMS OF 1,500 PATIENTS

Abnomality No. (%) of

Patients

Lungs, mediastimtim, pleura Pneumonia, atelectasis

48(3.2)

41

Hilar or pulmonary calcifications 3

Mediastinal masses (posierior mediastinal 3 neurofibroma, 1;bronchopulmonary

foregut malformations & pulmonary

sequestrations, 2)

Thyroglossal cyst 1

Skeletal System 23 (1.6)

Scoliosis 19

Hemivertebrae & spina bifida 5

Fractures of thoracic skeleton 2 dsteogenesis imperfecta 1

Heart and vessels 38 (2.5)

Cardiomegaly 25

Abnormal cardiac silhouette 13

Abnormal pulmonary vessels 8

Dextrocardia/dextroversion 8

postponement or cancellation of the surgical procedure?

3. Did the roentgenographic findings alter the

subsequent anesthetic, surgical, or medical man-agement?

RESULTS

Of the 1,500 cases examined, 111 patients were interpreted as having at least one roentgeno-graphic abnormality (Tables I and II). Twenty-two patients had multiple abnormalities. Seventy-one patients had unsuspected but medically significant pulmonary, cardiac, or skeletal roent-genographic abnormalities that required follow-up examination or treatment. Pneuinonia, atelec-tasis, hilar or pulmonary calcification, mediastinal mass, foregut malformation, unbalanced hemiver-tebrae with osteogenic scoliosis, scoliosis of other etiology, fracture of the thoracic skeleton, and congenital heart lesion were considered as signif-icant abnormalities. Balanced hemivertebrae and/or spina bifida without scoliosis or neuro-logic abnormality, asymptomatic rib abnormali-ties and/or pectus excavatum, and eventration of the diaphragm were considered as incidental findings.

In 30 patients, the history, physical

examina-tion, or prior chart notations indicated that the roentgenographic findings were either known or suspected at the time of the preoperative chest roentgenographic examination. Three of these

patients also had significant unsuspected abnor-malities.

Surgery was postponed in 1 1 instances as a direct result of th unsuspected roentgenogr#{225}phic findings. These 1 1 children were undergoing elective surgical procedures and showed large pneumonic consolidations. Ten of these children returned for surgery in one month and the follow-up chest roentgenograms were normal. One patient was lost to the follow-up when the family moved out oftown. In 12 instances, surgery was performed after consultation with the surgeon and the anesthesiologist and/or the cardiologist. The anesthetic technique was altered following the report of unsuspected roentgenographic find-ings in 34 patients (Table III). The changes in the anesthetic technique included the use of cardiac monitors, increased observation time of the patient, assisted respiration, and suction of the

respiratory tract. There was no record of

unsus-pected roentgenographic findings altering surgi-cal technique or leading to postoperative compli-cations.

DISCUSSION

With the decreasing incidence of pulmonary tuberculosis, the increasing concern over the radiobiologic effects of roentgenographic expo-sure, and the rapidly rising cost of medical care, several authors’#{176}‘ ‘ have recommended that routine preoperative chest roentgenographic examinations on healthy children should not be performed. The present prospective study of 1,500 consecutive preoperative chest x-ray exam-inations at Minneapolis Children’s Health Center demonstrated that 7.5% of these routine preoper-ative chest films demonstrated one or more abnormal roentgenographic findings. In 4.7% of the examined thildren, the abnormalities were considered medically significant and were entire-ly unsuspected by the primary physician. In 41 instances, pneumonia and/or atelectasis was iden-tified in either or both lungs. Many of these patients had no clinical or auscultative findings to identify the pulmonary abnormality. Even on some retrospective clinical examinatkms, no din-ical signs could be found at the site of the roentgenographic abnormality.

In three instances, clinically unsuspected,

asymptomatic mediastinal masses were identified. Two patients had bronchopulmonary foregut malformation and extralobal pulmonary seques-trations. One boy had a large posterior medias-tinal neurofibroma. In three large combined series on mediastinal masses,’2’4 42.5% of the mediastinal masses were asymptomatic. In the

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TABLE II TABLE III

INCIDENTAL ABNORMALiTIES ON PREOPERATIVE CHEST

ROENTGENOGRAMS

Abnormality No. (%) of

Patients#{149}

Skeletal system 32(2.1)

Rib anomalies, asymptomatic 17

Spina bifida 7

Balanced hemivertebrae 5 Pectus excavatum, asymptomatic 5 Lung, pleura, mediastinum 4(0.2)

Pleural thickening 3

Eventration of diaphragm 1

same three combined series, 38.2% of mediastinal masses were malignant. Lyons et al.15 reviewed 782 mediastinal masses and noted that several of them were asymptomatic, but did not specify an

exact percentage. Forty-two percent of the

mediastinal masses in their study were malignant.

A majority of the asymptomatic mediastinal

masses in all four series were identified on routine chest examinations. Thus, early identification of mediastinal masses cannot be overemphasized.

Nineteen instances of unsuspected s#{231}oliosis, five of which were osteogenic, were noted. Early diagnosis and treatment of scoliosis is required to prevent serious deformity from developing and to avoid major operative intervention.’6

Thirty-eight patients showed abnormalities of the cardiovascular system. In 21 instances the cardiac disease was documented in the hospital record at the time of the preoperative chest examination, though the information was not available to the radiologist at the time of the evaluation of the chest roentgenogram. Of the remaining 17 patients only six had a subsequent cardiovascular workup. Cardiac catheterization demonstrated patent ductus arteriosus in one patient, a ventricular septal defect in another. The other four patients had only clinical and

ECG examinations. One of these four had

idio-pathic left ventricular hypertrophy, another a functional heart murmur, and the other two had

normal cardiovascular signs. In 1 1 patients, no note of cardiovascular follow-up was available in the hospital record. The lack of such follow-up may be related to the fact that the reports of the roentgenographic interpretations were furnished to the surgeons who in many instances were not the primary physicians.

We believe that recognition of unsuspected pneumonia in children undergoing elective surgi-cal procedures, diagnosis of three mediastinal

Dnuxrr RESULTS OF PREOPERATIvE ABNORMAL CHEST

.

FINDINGS

No. (%) of Patients

Postponement of surgery 11

Surgery following anesthesia & cardiology 12

consultation

Altered anesthetic technique 34

Total 57(3.8)

tumors, identification of scoliosis in 19 patients, and the diagnosis of previously unrecognized correctable congenital cardiac lesions in two patients (only six of 17 patients had the necessary workup) justify the expenditure of approximately $22,500 for the 1,500 preoperative chest roent-genograms in this study. In addition, normal preoperative chest roentgenograms are of tre-mendous help as baseline studies for future din-ical problems if the records in the pediatric institutions are properly maintained.

CONCLUSION

1. In a prospective analysis of 1,500 preopera-tive chest x-ray examinations, 7.5% of the patients demonstrated at least one roentgenographic abnormality, with 4.8% of the examined patients demonstrating a totally unsuspected, significant roentgenographic anomaly.

2. In 3.8% of the examined patients, surgery was either postponed or cancelled or the an#{232}s-thetic technique altered as a direct result of the roentgenographic identification of unsuspected abnormalities.

3. The routine preoperative chest roentgeno-graphic examination is medically. and economi-cally justified and essential in pediatric patients, provided the evaluation of these chest roentgeno-grams is performed prior to surgery and careful clinical follow-up examination is obtained in every instance of reported abnormality.

REFERENCES

1. Peters ES: Mass x-ray surveys. Med Serv J Can 22:922, 1966.

2. MacKenzie CJG: Non-tuberculous chest disease found

in a mass x-ray survey in Vancouver, B.C. Can Med Assoc J 94:1257, 1966.

3. Saenger EL: Radiologists, medical radiation, and the

public health. Radiology 92:658, 1969.

4. Mass survey by chest radiography, editorial. Can Med Assoc J 103:1081, 1970.

5. Jarman TF: Mass radiography. Br Med J 1:365, 1970.

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672 CHEST X.RAY EXAMINATIONS

non-tuberculous chest disease found at “Operation

Doorstep,” Vancouver, 1964. Can Med Assoc J

103:1019, 1970.

7. Taylor LS: Inefficient use of x-rayS in diagnostic radiol-ogy. Am J Roentgenol Radium Ther NucI Med 111:635, 1971.

8. Rourke AJJ: Are all those x-rays and tests really neces-sary? Mod Hosp 118:106, 1972.

9. Hahn DR. Van Farowe DE: Misuse and abuse of

diagnostic x-ray. Am J Public Health 60:250, 1970.

10. Brill PW, Ewing ML, Dunn AA: The value (?) of routine chest radiography in children and adolescents. Pedi-atrics 52:125, 1973.

1 1. Sagel SS, Evens RG, Forrest JV, et al: Efficacy of routine

screening and lateral chest radiographs in a hospital

based population. N Engl J Med 291: 1001, 1974.

12. Daniel BA, Walter LD, Edwards WH, et al: Mediastinal tumors. Ann Surg 151:783, 1960.

13. Joseph WL, Murray JF, Mulder DG: Mediastinal

tumors: Problems in diagnosis and treatment. Dis Chest 50:150, 1966.

14. Street BG, Thomas DE: Mediastinal masses. AMA Arch Surg 77:105, 1958.

15. Lyons HA, Calvy GL, Sammons BP: The diagnosis and

classification of mediastinal masses: A study of 782 cases. Ann Intern Med 51:897, 1959.

16. Winter RB, Moe JH: A plea for the routine school

examination of children for spinal deformity. Minn

Med 57:419, 1974.

AMERICAN ACADEMY OF PEDIATRICS RESIDENCY FELLOWSHIPS

STIPULATIONS

To enable young physicians to complete their pediatric training, the

American Academy of Pediatrics will grant a small number of fellowships of $500 to $2,500 each to pediatric interns and residents for the year beginning

J

uly 1. Candidates must meet the following requirements:

1. Be legal residents of the United States or Canada;

2. Have completed, or will have completed by July 1, a qualifying approved

internship (PL-0) or have completed a P1-i program, and have made a definite

commitment for a first year pediatric residency (P1-i or P1-2) acceptable to the

American Board of Pediatrics; or

3. Be pediatric residents (P1-i, P1-2, or P1-3) in a training program and have

made a definite commitment for another year of residency in a program

acceptable to the American Board of Pediatrics;

4. Have real need of financial assistance; and

5. Support their application with a letter from the Chief of Service

substantiating the above requirements; if a change in residency training

program is contemplated (i.e., moving to another institution), a letter from the

chief of this service certifying acceptance to this program will also be necessary.

The fellowships have been provided through grants to the American

Academy of Pediatrics by Mead Johnson Laboratories and the Gerber Products

Company.

Aithough the fellowship awards are intended primarily for the support of first and second year pediatric residents, it is also recognized that some physicians may desire a third or fourth year of pediatric residency. Up to 25%

of the fellowships may be awarded to persons in this category. Consideration will be given to geographic spread of awards, and preference will be exhibited

for well-qualified but smaller training centers which perhaps have fewer resources for residents in training than do some of the larger centers.

The Committee on Residency Fellowships of the American Academy of Pediatrics will make final decision on the granting of the Awards. Those interested in applying may write to Jean D. Lockhart, M.D., Department of Committees, American Academy of Pediatrics, P.O. Box 1034, Evanston,

Illinois

60204,

for application forms.

The deadline for the receipt of applications will be March 1.

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1977;60;669

Pediatrics

Shashikant M. Sane, Robert A. Worsing, Jr., Cornelius W. Wiens and Rajiv K. Sharma