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ORIGINAL ARTICLE

A study on role of chest X‑rays in children above

5 years admitted with asthma exacerbation
Sujonitha John, Jaidev MD, Habeeb Ullah Khan, Pavan Hegde

ABSTRACT
Context: Asthma is a heterogeneous disease characterized by chronic airway inflammation that causes airway hyperresponsiveness.
The diagnosis of asthma is mainly clinical, and chest X‑rays are not required for the diagnosis or grading of severity of
disease. Aim: The aim of this study is to look at the frequency of abnormalities and the pattern of abnormalities in chest X‑rays
done in children above 5 years admitted with acute asthma and to analyze if chest X‑ray reports altered the ongoing treatment
plan. Settings and Design: It was a retrospective study done in a tertiary care hospital. Methods: Data were collected from case
records of children above 5 years admitted with acute asthma between November 2014 and October 2017. Statistical Analysis: The
statistical analysis was done using Chi‑square and Fisher’s exact test. Results: A total of 114 children were included in the study,
and 84 (74%) had chest X‑rays performed of which 88% were normal. Nineteen (22.6%) complied with standard guidelines, and the
reason for performing chest X‑rays in these children was the presence of focal clinical chest signs. When there were focal clinical
findings, the possibility that chest X‑ray would be abnormal was 47.37%. When there were no focal clinical findings, the possibility
that chest X‑ray would be normal was 98.46%. The sensitivity of chest X‑rays with clinical correlation was 90% and specificity was
86.48%. Hence, routine chest X‑rays in the standard treatment of acute asthma are not necessary, especially when there are no focal
clinical findings. Conclusion: Chest X‑ray is not required in the management of acute asthma in children above 5 years responding
to standard treatment. Chest X‑rays should be ordered in the management of acute asthma only when indicated, thereby reducing
unnecessary exposure to radiation.
Key Words: Acute asthma, airway hyperresponsiveness, chest X-rays

Introduction asthma. According to the current guidelines from the

Asthma is a heterogeneous disease characterized
by chronic airway inflammation that causes airway
hyperresponsiveness. It is defined by the history of
respiratory symptoms such as wheeze, shortness of breath,
chest tightness, and cough that vary over time and in
intensity, together with variable expiratory airflow limitation.[1]
The diagnosis of asthma is mainly clinical, and chest
X‑rays are not required for the diagnosis or grading of
severity of disease. Chest X‑ray may be valuable when
there is an inadequate response to treatment, clinical
suspicion of an alternative diagnosis, or complication
of asthma.[2]
International Committee on Radiation Protection,
the stochastic exposure risks increase in a linear,
dose‑response manner, and therefore, repetitive
radiation exposures are believed to incrementally
increase cancer risk in children. The radiation
exposure for every chest X‑ray is equal to 0.02 mSv
(millisievert).[3] Awareness is one of the greatest means
to reduce radiation exposure.[4]
Department of Paediatrics, Father Muller Medical College and Hospital,
Mangalore, Karnataka, India
Address for correspondence: Dr. Jaidev MD,
Department of Paediatrics, Father Muller Medical College Hospital,
Kankanady, Mangalore ‑ 575 002, Karnataka, India.
E‑mail: jaidev.devdas@gmail.com

In routine practice, unwarranted chest X‑rays are

ordered frequently in the management of acute This is an open access journal, and articles are distributed under the
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DOI: How to cite this article: John S, Jaidev MD, Khan HU, Hegde P.
10.4103/mjmsr.mjmsr_16_18 A study on role of chest X-rays in children above 5 years admitted with
asthma exacerbation. Muller J Med Sci Res 2018;9:87-9.

© 2018 Muller Journal of Medical Sciences and Research | Published by Wolters Kluwer - Medknow 87
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John, et al.: Role of chest X‑rays in children above 5 years admitted with asthma exacerbation
Methods
Our study was a retrospective observational time‑bound
study done in a tertiary care hospital. All children above
5 years of age admitted with exacerbation of asthma
between November 2014 and December 2017 were
included in this study. Children below 5 years and those
children with diagnosis such as episodic viral wheeze,
bronchiolitis, and wheeze‑associated lower respiratory
tract infection were excluded from the study. Data were
collected retrospectively from case records of children
fulfilling the inclusion criteria using a predesigned pro forma.
Chest X‑rays were reviewed by a consultant radiologist and
compared against clinical findings documented in the case
records. Notes were screened meticulously to see if chest
X‑ray findings altered the standard treatment of asthma
and whether the X‑rays done were in concordance with
standard guidelines. Chi‑square test and Fisher’s exact
test were the statistical methods applied. The study was
approved by the Institutional Ethics Committee.
Results
A total of 114 children above 5 years of age admitted with
acute asthma were included in our study. Sixty‑five (57%)
children were boys, while girls were 49 (43%). There was
a history of recurrent wheeze for more than a year in
58 (51%) children, and 50 (44%) had a history of wheeze
for more than 6 months but less than a year [Figure 1].
Frequency, compliance with guidelines, and reasons
for performing chest X‑rays
Out of 114 children, 84  (74%) had chest X‑rays
performed, while 30 (26%) did not have chest X‑rays.
Among the children who had chest X‑rays performed,
19  (22.6%) complied with standard guidelines, and
the reason for performing chest X‑rays in these
children was the presence of focal clinical chest
signs [Figure 1].
Children with acute asthma
n = 114
Complied with guidelines
19 (22.6%)
Total chest X-rays done
84 (74%)
Did not comply with
guidelines 65 (77.3%)
Normal chest X-ray Abnormal chest X-ray
74(88%) 10 (12%)
9 (90%) correlated 1 (10%) did not
clinically correlate clinically
Figure 1: Flow diagram of children in the study
88 Muller Journal of Medical Sciences and Research | Volume 9 | Issue 2 | July - December 2018
Chest X‑ray and clinical correlation
Out of 84 chest X‑rays which were performed, 74 (88%)
were normal. Among 10 abnormal chest X‑rays, 9
correlated clinically [Figure 1]. Consolidation with or
without synpneumonic effusion was observed in nine and
an incidental finding of a hiatus hernia was found in one.
Focal chest findings were present in 19 out of 114 children.
Chest X‑ray was performed in all children with focal chest
findings, of which 10 (52%) were normal. The possibility
that chest X‑ray would be abnormal in the presence of
focal clinical findings was 47.37%. On the other hand,
in the absence of focal clinical findings, the possibility
that the chest X‑ray would be normal was 98.46%. The
sensitivity of chest X‑ray abnormalities with focal clinical
signs was 90%, while specificity was 86.49%, which was
statistically highly significant (P < 0.001) [Table 1].
Modification in standard treatment of acute asthma
based on abnormal chest X‑rays
Standard treatment of acute asthma remained unaltered
in 74 children with normal chest X‑rays. On the
other hand, in all the 10 children with abnormal
chest X‑rays, the standard treatment of asthma
was modified (antibiotics in nine and surgery for
hiatus hernia in one) which was statistically highly
significant (P < 0.001) [Table 2].
Discussion
Our study comprised 114 children above 5 years of age
admitted with acute asthma. The results highlighted
that chest X‑rays were done in 84  (74%) children, of
which 19  (22.6%) complied with standard guidelines.
The presence of focal clinical finding was the reason for
performing chest X‑rays in children who complied with
standard guidelines. Similarly, in a retrospective study
done by Roback and Dreitlein, out of 298 children below
18 years admitted with acute wheeze, 121 (40%) had
chest X‑rays performed and 89 (73.6%) complied with
standard guidelines. Localized wheeze, crepitations, and
decreased air entry were the indications for performing
chest X‑rays in this study.[5]
In our study, chest X‑rays were done in 84 (74%) children,
and 74 (88%) were normal while 10 (11%) were abnormal.
Although focal clinical signs were present in 19 children,
10 (52%) had normal chest X‑rays. Correlation between
clinical examination and chest X‑ray findings was present
in 9  (47.3%) children. In a single child with abnormal
chest X‑ray, there was an incidental finding of hiatus
hernia. The sensitivity of chest X‑ray abnormalities with
focal clinical signs was 90% and specificity was 86.49%.
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John, et al.: Role of chest X‑rays in children above 5 years admitted with asthma exacerbation
Table 1: Chest X‑ray and clinical correlation
Chest X‑ray abnormal Chest X‑ray normal Total
Focal clinical 9 10 19
findings
No focal 1 64
clinical findings
Total 10 74
P<0.001
Table 2: Modification in standard treatment of acute
asthma based on chest X‑rays
Change in treatment No change in treatment Total
Abnormal 10 0 10
chest X‑ray
Normal 0 74
chest X‑ray
Total 10 74
P<0.001
In contrast, Brooks et al. in their study on significance of
chest X‑rays in children with acute asthma showed that
out of 128 chest X‑rays that were performed, 36 (28%)
were abnormal, of which 3 (8%) correlated clinically.[6]
In our study, 74 children with normal chest X‑rays, the
standard treatment of acute asthma was unaltered, while
in 10 (100%) children with abnormal chest X‑rays, standard
treatment of acute asthma was modified (addition of
antibiotics in nine and surgery for hiatus hernia in one child)
which was statistically highly significant (P < 0.001). Similarly,
Roback and Dreitlein showed that out of 121 children with
acute asthma who received chest X‑rays, 29 (24%) were
abnormal and ongoing treatment was altered in all these
children. In addition, clinical findings that influenced ongoing
treatment were the presence of localized wheeze and
localized crepitations in this study.[5]
In contrast, Brooks et al. in their study showed that out of
36 (28%) abnormal chest X‑rays, treatment plan of acute
asthma was altered in only 3 (8%), and hence, they had
suggested that routine chest X‑rays in the management
of acute asthma were unnecessary.[6]
In summary, we found that 88% of the children with acute
asthma who had chest X‑rays performed were normal, while
abnormalities were noted in 12%. When there were focal
clinical findings, the possibility that chest X‑ray would be
abnormal was 47.37%. When there were no focal clinical
findings, the possibility that chest X‑ray would be normal was
98.46%. The sensitivity of chest X‑rays with clinical correlation
was 90% and specificity was 86.48%. Hence, routine chest
X‑rays in the standard treatment of acute asthma are not
necessary, especially when there are no focal clinical findings,
which have also been suggested by the guidelines of British
Thoracic Society and Global Initiative for Asthma.[1,7]
Muller Journal of Medical Sciences and Research | Volume 9 | Issue 2 | July - December 2018 89
Conclusion
Chest X‑ray is not required in the management of
acute asthma in children above 5 years responding to
65 standard treatment. Chest X‑rays should be ordered in
the management of acute asthma only when indicated,
84 thereby reducing unnecessary exposure to radiation.
Limitations
The limitations of our study were that it was a retrospective
study; hence, the reliability of data was solely based
on the documentation in case records. The inclusion
of cases was based on the documented diagnosis
74 at discharge by the treating clinician. Children below
5 years of age were excluded as other clinical entities
84
such as viral‑induced wheeze and bronchiolitis may
mimic asthma and diagnosis of asthma may be difficult.
Spirometry and peak flow assessments are also difficult
in this age group as they are effort dependent.
Acknowledgment
The authors would like to acknowledge Dr. Sucharita
Suresh for statistical analysis of data.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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Management and Prevention 2017. Available from: https://
ginasthma.org/2017-gina-report-global-strategy-for-asthma-
management-and-prevention/. [Last accessed on 2018 Mar 01].
2. National asthma Council Australia. Asthma Management
Handbook 2006. Melbourne (Australia): National Asthma Council
Australia; 2006.
3. The 2007 recommendations of the international commission
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2007;37:1‑332.
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Reiman RE, et al. Cumulative radiation exposure and cancer risk
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