Questionable Statement

Preoperative Risk Assessment—From Routine Tests to Individualized Investigation by Dr. med. Andreas B. Böhmer, Prof. Dr. med. Frank Wappler, Prof. Dr. med. Bernd Zwißler in issue 25/2014

The authors state that the sensitivity of chest X-rays is so low that they should only be obtained when a pertinent diagnosis is clinically suspected. To support this statement reference is made to two publications.

In the 40-year-old publication it is stated that a chest x-ray is essentially not indicated in asymptomatic patients under 20 years of age; a PA x-ray is indicated in patients aged 20 to 39 years; a PA and lateral chest x-ray is required in patients older than 40 years (1). The second publication investigates to what extent a preoperative chest x-ray triggers further actions and whether postoperative complications occur more frequently when no preoperative radiograph was obtained (2). The authors arrive at the conclusion that it is not necessary to obtain a chest x-ray in patients under age 70 with no risk factors; no recommendation is made for older patients. Thus, both citations cannot be used to suggest that chest x-rays are not necessary. From the perspective of anesthesiology and with a focus on perioperative complications, it may be justified to question the benefit of chest radiographs. However, it is a questionable approach to only obtain an x-ray in relation to the planned intervention and not based on a holistic understanding of the patient. In addition, it is negligent to state that the sensitivity of x-rays to diagnose cardiopulmonary disease is low. A screening study on the early detection of lung cancer showed that in asymptomatic smokers with a history of at least 30 pack years, chest radiography detected lung cancer in 3.5% of cases (3). The incidental finding in a chest x-ray is the only chance to detect lung cancer in an early, operable stage.

Taken together, these data suggest that preoperative chest x-rays in suitable quality should be requested, at least in smokers.

DOI: 10.3238/arztebl.2015.0070a

Prof. Dr. med. Hendrik Dienemann, Thoraxchirurgie

Prof. Dr. med. Claus Peter Heußel, Diagnostische und Interventionelle Radiologie mit Nuklearmedizin

Prof. Dr. med. Michael Thomas, Onkologie der Thoraxtumoren

Prof. Dr. med. Felix Herth, Pneumologie und Beatmungsmedizin

PD Dr. med. Werner Schmidt, Anästhesiologie und Intensivmedizin

Thoraxklinik, Universität Heidelberg

Conflict of interest statement

Prof. Heußel owns shares of Stada and GSK. He holds the patent „Method and Device For Representing the Microstructure of the Lungs, „IPC8 Class: AA61B5055FI, PAN: 20080208038”. He has received consultancy fees from Schering-Plough, Pfizer, Basilea, Boehringer Ingelheim, Novartis, Roche, Astellas, Gilead, MSD, Lilly, Intermune, and Fresenius. He is receiving research funding from Siemens, Pfizer, MeVis and Boehringer Ingelheim. He has received fees for presentations from Gilead, Essex, Schering-Plough, AstraZeneca, Lilly, Roche, MSD, Pfizer, Bracco, MEDA Pharma, Intermune, Chiesi, Siemens, Covidien, Pierre Fabre, Boehringer Ingelheim, Grifols, and Novartis.

Prof. Dienemann, Prof. Thomas, Prof. Herth, and PD Dr. Schmidt declare that no conflict of interest exists..

References

1. Sagel SS, Evens RG, Forrest JV, et al.: Efficacy of routine screening and lateral chest radiographs in a hospital-based population. N Engl J Med 1974; 291: 1001–4.

2. Joo HS, Wong J, Naik VN, et al.: The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth 2005; 52: 568–74.

3. The National Lung Screening Trial Research Team: Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365: 395–409.

4. Böhmer AB, Wappler F, Zwißler B: Preoperative risk assessment—from routine tests to individualized investigation. Dtsch Arztebl Int 2014; 111: 437–46.