Rationale and Comments

Respiratory illnesses are among the most common reasons for pediatric emergency department visits, with wheezing being a frequently encountered clinical finding. For children presenting with first-time wheezing or with typical findings of asthma, bronchiolitis, or croup, radiographs rarely yield important positive findings and expose patients to radiation, increased cost of care, and prolonged emergency department length of stay. National and international guidelines emphasize the value of the history and physical examination in making an accurate diagnosis and excluding serious underlying pathology. Radiography performed in the absence of significant findings has been associated with the overuse of antibiotics. Radiographs should not be routinely obtained in these situations unless findings such as significant hypoxia, focal abnormalities, prolonged course of illness, or severe distress are present. If wheezing is occurring without a clear atopic etiology or upper respiratory tract infection symptoms (e.g., rhinorrhea, nasal congestion, fever), appropriate diagnostic imaging should be considered on a case-by-case basis.

Sponsoring Organizations

• American Academy of Pediatrics – Section on Emergency Medicine and the Canadian Association of Emergency Physicians

Sources

• AAP guideline

Disciplines

• Pulmonologic
• Pediatric

References

• Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.
• Trottier ED, Chan K, Allain D, et al. Managing an acute asthma exacerbation in children. Paediatr Child Health. 2021;26(7):438-439.
• Shah SN, Bachur RG, Simel DL, et al. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471.
• Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433.
• National Heart, Lung, and Blood Institute. Expert Panel Report 4: Guidelines for the Diagnosis and Management of Asthma; National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007:391.