When radiologists use common terms in their reports of chest radiograph findings, they assume that clinicians use the same terms as well. However, some radiologic descriptors may lead to unintended diagnostic conclusions, as pediatric radiologists discovered after conducting a survey of pediatricians in the Nashville, TN, area.
Researchers at Vanderbilt University in Nashville decided to study how well radiologists and pediatricians were communicating after a resident asked about the term peripheral airway disease. The research group was led by Dr. Stephanie Spottswood, associate professor of radiology at Monroe Carell Jr. Children's Hospital at Vanderbilt. The study was published in the April 2009 issue of Pediatric Radiology (Vol. 39:4, pp. 348-353).
The researchers conducted an online survey of their referring physician database to prospectively evaluate pediatricians' interpretations of terms used to describe common pediatric airway and pulmonary parenchymal pathology that they commonly used in reports of chest radiographs. The radiologists also wanted to determine how choice of language in a report influenced patient management.
A 17-question survey was developed with input from pediatric radiologists and pulmonologists. The survey asked what conclusions were drawn when the terms peripheral airway disease, airspace consolidation, and focal infiltrate were used. Survey participants were provided with multiple choice selections for each term, and they were allowed to select more than one response.
The survey also included two clinical scenarios in which a previously healthy 3-year-old child presented with fever, cough, and shortness of breath, but without marked respiratory distress. In one scenario, wheezing could be detected during the physical examination, and in the other scenario, it could not be.
For each scenario, respondents were asked how they would treat the child if the chest radiograph was reported as normal, peripheral airway disease, focal airspace consolidation, or focal infiltrate. Four multiple choice treatment options were offered. Finally, the survey asked if chest radiography was a useful determinant of asthma.
The survey was emailed to 562 clinicians in September 2007 with a 30-day response window. The 20% response by 112 physicians included 69.6% general pediatricians, 21.4% pediatric residents, 8% pediatric subspecialists, and 1% nurse practitioner or physician's assistant.
The results of the survey were surprising, Spottswood told AuntMinnie.com. "We had thought that the terms peripheral airway disease, airspace consolidation, and focal infiltrate were fairly straightforward and well understood. However, some terms were misinterpreted to the extent that a patient potentially might not receive appropriate treatment," she said.
Peripheral airway disease refers to a type of inflammatory disease that manifests as parahilar interstitial thickening, leading to indistinct hilar structures on chest radiographs. It is usually accompanied by hyperinflation, often in smaller children, and occasionally by areas of atelectasis, or collapsed lung tissue, secondary to mucus plugging. The disease can be seen in children with reactive airway disease (asthma) or those with other inflammatory conditions such as viral bronchiolitis, according to Spottswood.
However, only 62 respondents selected asthma as the conclusion they reached. Twenty-five percent, or 28 respondents, equated a report containing the term peripheral airway disease as being a normal radiograph, possibly because of the absence of findings more suggestive of bacterial pneumonia. Of the 205 responses from 97% of the respondents, an additional 61.5% of the responses equated the term with viral pneumonia and 44% as viral pneumonia and asthma.
Focal airspace consolidation, which is meant to convey the presence of consolidated lung or pneumonia, was interpreted by 69.6% as pneumonia but, surprisingly, was interpreted by 83% of the respondents as atelectasis. The term focal infiltrate, on the other hand, which refers to any foreign substance that spreads through the interstices of the lung and is often used to describe pneumonia, was interpreted as pneumonia by 100% of respondents and as atelectasis by 22.3%.
With the diversity of responses, children without pneumonia who did not need antibiotics might receive a prescription for them, contributing to the current problem of antibiotic resistance. Furthermore, other patients with pneumonia, who should be prescribed antibiotics, may not receive them.
Selection of treatment choices for the two clinical scenarios of a wheezing and nonwheezing child also differed.
No. of respondents who recommended treatment of wheezing children based on radiology report findings
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No. of respondents who recommended treatment of nonwheezing children based on radiology report findings
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| Source for both tables: Spottswood SE, Liaw K, Hernanz-Schulman M, et al. The clinical impact of the radiology report in wheezing and nonwheezing febrile children: a survey of clinicians. Pediatr Radiol. 2009;39:348-353. |
Because chest radiographs play an integral role in triaging and managing children with respiratory symptoms due to airway and pulmonary parenchymal disease, pediatricians and radiologists should be in agreement on the meaning of terms used to define the exam findings. The Fleischner Society, a Houston-based multidisciplinary medical society dedicated to the diagnosis and treatment of chest diseases, developed a common lexicon of descriptive terms in chest radiology that was updated in 2008.
"While the Fleischner Society lexicon contributes to the standardization of language used in the findings of chest radiography, its utility is limited if the pediatricians are not aware of this lexicon, or if their access to it is not facilitated," Spottswood said.
Spottswood and colleagues suggested that adopting structured reporting with consistent, defined, and unambiguous use of descriptive radiologic language may help eliminate misinterpretations by referring physicians. They also recommended that definitions of potentially ambiguous terms be included in the reports.
The results of the survey have led to a department decision to use consistent, precise language, according to Spottswood.
"If we think that the radiograph shows an infection, we now add the term pneumonia. If we think the patient has asthma, we use the phrase 'findings are consistent with asthma,' " she explained.
Because the study was conducted in a specific geographic region, namely, metropolitan Nashville, Spottswood and colleagues recommended that the survey be replicated in other geographic regions of the U.S. and Canada. "We will then know if this is a geography-specific problem and concern or if it is a national or international one. We are willing to share our questionnaire with other researchers to determine this."
By Cynthia E. Keen
AuntMinnie.com staff writer
April 3, 2009
Related Reading
Speech recognition and structured reporting brings advantages, drawbacks, May 12, 2008
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