From the Guidelines
Routine chest X-rays and laboratory tests are generally not recommended for children with asthma during acute exacerbations or for routine monitoring. The evidence supporting this approach comes from multiple clinical guidelines and studies, including the European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years 1, which recommends against the use of unnecessary tests in the diagnosis of asthma. Physical examination, patient history, and assessment of response to bronchodilator therapy provide more valuable diagnostic information than imaging or laboratory studies in most cases.
According to the guidelines, diagnosis of asthma in children should be based on at least two objective test results, with spirometry, BDR, and FeNO being first-line tests in the asthma diagnostic pathway 1. The guidelines also recommend against trials of treatment where an improvement of symptoms alone after a period of empiric asthma preventer medication is used to confirm the diagnosis.
Chest X-rays expose children to unnecessary radiation and should be reserved for cases where complications like pneumonia, pneumothorax, or foreign body aspiration are suspected based on clinical findings such as focal chest findings, asymmetric breath sounds, or fever. Similarly, laboratory tests including complete blood counts and basic metabolic panels rarely provide actionable information in uncomplicated asthma and increase healthcare costs and patient discomfort. Pulse oximetry and peak flow measurements are more appropriate monitoring tools for assessing asthma severity and response to treatment.
This approach aligns with the principles of high-value care, reducing unnecessary testing while maintaining quality care through appropriate clinical assessment and targeted interventions for children with asthma, as discussed in the European Respiratory Society guidelines 1. By following this approach, healthcare providers can prioritize the most effective and efficient diagnostic methods, ultimately improving patient outcomes and reducing unnecessary costs.
Key points to consider in the diagnosis and management of asthma in children include:
- The use of spirometry, BDR, and FeNO as first-line tests in the asthma diagnostic pathway
- The importance of physical examination, patient history, and assessment of response to bronchodilator therapy in diagnosis and management
- The limited role of chest X-rays and laboratory tests in routine monitoring and diagnosis
- The need for targeted interventions and appropriate clinical assessment to provide high-value care for children with asthma.
From the Research
Evidence for Not Doing a Chest X-ray and Labs in a Child with Asthma
- The diagnosis of asthma is primarily clinical, made from a combination of historical features and clinical examination findings 2.
- Additional testing, such as chest x-ray and blood gas measurements, is reserved for select patients, implying that not all children with asthma require these tests 2.
- The severity of asthma exacerbations is determined by clinical presentation, peak expiratory flow rates, and vital signs, which can be assessed without the need for chest x-rays and labs 2.
- Spirometry aids in the diagnosis of asthma and measurement of severity, but it is not always required, and other diagnostic methods can be used 2.
- The use of imaging in asthma has historically been limited to excluding alternative diagnoses, and is not needed to confirm a diagnosis of asthma 3.
- Asthma management guidelines focus on clinical assessment and symptom control, rather than relying on laboratory tests and imaging 4, 5.
- Treatment of asthma exacerbations can be guided by clinical presentation and response to therapy, without the need for routine chest x-rays and labs 6.