What guidelines should I follow for ordering chest X-rays in patients with respiratory symptoms?

When considering ordering chest X-rays for patients presenting with respiratory symptoms, the following guidelines should be followed:

• Suspected Cancer (NICE NG12):
  • Consider an urgent chest X-ray (to be done within 2 weeks) for patients aged 40 and over with a persistent or recurrent chest infection ¹.
  • Offer an urgent chest X-ray (to be done within 2 weeks) for patients aged 40 and over with unexplained chest pain who have ever smoked or been exposed to asbestos ¹. This also applies if unexplained chest pain is accompanied by cough, fatigue, shortness of breath, weight loss, or appetite loss ¹.
  • Offer an urgent chest X-ray (to be done within 2 weeks) for patients aged 40 and over with an unexplained cough who have ever smoked or been exposed to asbestos ¹. This also applies if an unexplained cough is accompanied by fatigue, shortness of breath, chest pain, weight loss, or appetite loss ¹.
  • Offer an urgent chest X-ray (to be done within 2 weeks) for patients aged 40 and over with unexplained shortness of breath who have ever smoked or been exposed to asbestos ¹. This also applies if unexplained shortness of breath is accompanied by cough, fatigue, chest pain, weight loss, or appetite loss ¹.
  • Consider an urgent chest X-ray (to be done within 2 weeks) for patients aged 40 and over with chest signs consistent with lung cancer, chest signs compatible with pleural disease, or finger clubbing ¹.
• Suspected Tuberculosis (NICE NG33):
  • Take a chest X-ray if chest X-ray appearances suggest tuberculosis (TB) ².
  • A chest X-ray is a routine diagnostic investigation for suspected pulmonary TB in adults, young people aged 16 to 17 years, and children aged 15 years or younger ².
  • For patients presenting with extrapulmonary TB, offer a chest X-ray to exclude or confirm coexisting pulmonary TB ².
• Suspected Bronchiectasis (CKS Bronchiectasis):
  • While chest X-ray is not recommended for diagnosis as findings are non-specific and may be normal, a baseline X-ray should be performed in people with suspected bronchiectasis ⁴.
• Palliative Care - Dyspnoea (CKS Palliative care - dyspnoea):
  • Chest radiography is a useful investigation to consider in all people with non-acute dyspnoea in a palliative care situation to assess lung disease and heart failure ⁵.
• Chronic Obstructive Pulmonary Disease (COPD) (NICE NG115):
  • Spirometry is the primary diagnostic tool for COPD ³. Chest X-ray is not routinely recommended for diagnosis, but symptoms like chest pain or haemoptysis should prompt consideration of alternative diagnoses ³.
• Chest Pain (CKS Chest pain):
  • Do not routinely organize a chest X-ray for stable angina unless other diagnoses, such as lung cancer, are suspected ⁶.
  • Arrange appropriate investigations if the cause of chest pain cannot be confidently established by clinical features alone ⁶.