Original Article

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

Authors: Zvi Shimoni, MD, Michal Rosenberg, MD, Leeor Amit, MD, Paul Froom, MD


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.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Expert Panel on Thoracic Imaging., McComb BL, Chung JH, et al. ACR Appropriateness Criteria® Routine Chest Radiography. J Thorac Imaging 2016;31:W13-W15.
2. Gupta SD, Gibbins FJ, Sen I. Routine chest radiography in the elderly. Age Ageing 1985;14:11-14.
3. Verma V, Vasudevan V, Jinnur P, et al. The utility of routine admission chest X-ray films on patient care. Eur J Intern Med 2011;22:286-288.
4. Fein AM, Feinsilver SH, Niederman MS. Atypical manifestations of pneumonia in the elderly. Clin Chest Med 1991;12:319-336.
5. Riquelme R, Torres A, el-Ebiary M, et al. Community-acquired pneumonia in the elderly. Clinical and nutritional aspects. Am J Respir Crit Care Med 1997;156:1908-1914.
6. Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA 2009;301:309-317.