Why is a chest X-ray (CXR) performed preoperatively?

From the Guidelines

Preoperative chest X-rays should be performed selectively rather than routinely for surgical patients, based on their clinical history, physical examination findings, and the type of planned surgery. The purpose of preoperative chest X-rays is to identify conditions that might increase surgical risk, such as pneumonia, pulmonary edema, pleural effusions, pneumothorax, or cardiac enlargement, which could necessitate postponing elective surgery or modifying anesthetic management 1.

Key Considerations

• Patients with known cardiopulmonary disease, symptoms of respiratory illness, or those undergoing thoracic or upper abdominal surgery may benefit from preoperative chest X-rays 1.
• Routine chest X-rays in asymptomatic, healthy patients have low yield and are not cost-effective 1.
• The decision to order a preoperative chest X-ray should be based on the patient's clinical history, physical examination findings, and the type of planned surgery, following a targeted approach rather than universal screening 1.

Evidence-Based Recommendations

• The American College of Physicians recommends that preoperative chest X-rays be reserved for patients with known cardiopulmonary disease or those undergoing upper abdominal, thoracic, or abdominal aortic aneurysm surgery 1.
• The American College of Cardiology/American Heart Association guidelines suggest that preoperative chest X-rays be performed selectively, based on the patient's clinical history and physical examination findings 1.
• A study published in the American Family Physician found that routine preoperative chest radiography in asymptomatic, otherwise healthy patients is not indicated, and that abnormal findings on preoperative screening radiography are most often chronic and predictable by the history or physical examination, and only rarely alter perioperative management 1.

From the Research

Preoperative Chest X-ray

The purpose of checking chest x-ray for preoperative evaluation is to identify potential risks and complications that may arise during surgery.

• The study 2 found that out of 500 chest x-rays, 109 (21.8%) had some abnormality, but only one patient had their surgery delayed due to a significant finding on the x-ray.
• Another study 3 suggested that routine chest x-rays may not be necessary before surgery, and that they rarely lead to changes in patient care.
• A study 4 recommended that preoperative chest x-ray should only be ordered for patients over 60 years of age, smokers, those with heart or respiratory disease, and those who have had contact with tuberculosis.

Indications for Preoperative Chest X-ray

The indications for preoperative chest x-ray are:

• Patients with signs or symptoms of acute or unstable cardiopulmonary disease 5
• Patients with a history of cardiopulmonary disease or signs and symptoms indicative of cardiopulmonary disease 5
• Patients who have had contact with tuberculosis and have not had any other chest x-ray taken within the past year 4

Limitations of Preoperative Chest X-ray

• The study 2 found that good medical history and clinical examination can save many patients from unnecessary chest x-ray.
• Another study 5 suggested that the clinical examination alone provides sufficient information to dictate any necessary changes in management in a majority of cases.
• The study 3 found that postoperative x-ray never led to changes in patient care in patients undergoing certain types of thoracic surgery.

Relationship between Preoperative Chest X-ray and Patient Outcomes

• The study 5 stated that the relationship between preoperative chest x-ray and patient outcomes, morbidity, and mortality is not known.
• The study 6 discussed the importance of preventing exacerbations in patients with chronic obstructive pulmonary disease (COPD), but did not specifically address the role of preoperative chest x-ray in this context.