Chest Radiography: Gold Standard for Pneumonia Diagnosis Assignment Sample

Introduction - Evaluating Chest X-rays for Detecting Community-Acquired Pneumonia

The aim of this essay is to critically analyse the evidence that underpins the diagnostic tool used in clinical practice. Therefore, for this proposed assessment Chest radiography or Chest X-ray has to be chosen as the diagnostic tool which is used to diagnose Pneumonia.

Chest Radiography or Chest X-ray is one of the most common and widely used diagnostic tools and the first procedure if any physician suspects the onset of heart or lung disease in an individual. Chest X-ray can be defined by ionizing radiation to produce an image of the inside of the chest or heart. This diagnostic tool mainly uses for evaluating the condition of the heart, lungs and chest wall, and sometimes this diagnostic tool is used to spot the reason for the shortness of breathing, persistent cough, chronic chest pain or the onset of any injury in the chest or heart. As Chest Radiography is one of the easy and fast processes, therefore, it is particularly used in emergency diagnosis process and treatment. The examination by this tool does not need any special preparation (Bitar et al., 2019). So, Chest x-ray or chest radiography can therefore be defined as the most commonly used diagnostic tool for x-ray examination. This tool is used to develop images of the lungs, hearts, blood vessels and bones located in the chest and spins. This tool in clinical practice is considered one of the most helpful x-ray tools which enable physicians to detect and treat any lung or heart-related diseases or injuries or conditions. Some common clinical use of Chest Radiography is to carry out the first imaging test to diagnose the symptoms like:

In this essay, the focus will be given on the critical assessment of different research articles, and journals to evaluate the use of Chest radiography or Chest x-ray for patients suffering from Pneumonia. The gold standard of this diagnostic tool is the PA projection, as it can reduce the risk of producing the lordotic image and cardiac magnification, as in an x-ray examination the patient is unlikely to lean backwards (Ye et al., 2015). In Chest Radiography, PA projection can also be considered the golden standard as it can provide an accurate evaluation of cardiothoracic ratio and measurement for removal of scapula shadow from the lung field. Pneumonia or CAP or community-acquired Pneumonia is now associated with a considerable disease burden across the world (Andronikou et al., 2017). It can be considered the major cause of substantial morbidity and mortality worldwide. One of the initial considerations to manage or reduce the risk of Pneumonia among the population is to carry out early diagnosis and here chest radiography is universally considered the "gold standard". Though, there are discrepancies observed in guidelines and recommendations to diagnose or detect pneumonia among the population or the use of routine chest radiography.

So, as the case against, to evaluate the diagnostic test or use of Chest Radiography or Chest X-ray as the diagnosis tool, here it is important to compare its performance to the "gold standard".

The purpose or aim of this proposed essay is to evaluate the evidence-based research articles and journals to evaluate the use of Chest X-rays in clinical practice. Therefore, in this case, the "gold standard" definition of pneumonia includes chest radiography- then there should not be any comparison (Andronikou et al., 2017). So, to meet the purpose of this essay, the discussion will be carried out on “What is pneumonia”, and “How accurately can chest X-ray be used to detect the onset or perseverance of Pneumonia?”

To meet the gold standard and the aim of this essay, in this assessment, an in-depth discussion on pneumonia and the use of Chest X-rays have to be carried out systematically. Or more specifically, existing literature and journals will be assessed or critically evaluated in this essay and focus will be given to the population who are diagnosed with pneumonia with an average body temperature of >=37.8 degree Celsius with chronic chest pain, rhonchi, rapid heart rate, dyspnoea, and the onset of rhinorrhea (Neuman et al., 2011). To critically analyse the existing literature for underpinning the use of Chest X-rays as a diagnostic tool for the clinical practice (diagnose and treat) for Pneumonia, the CASP tool will also be included in this assessment.

Main body

In the previous section, it has been mentioned that one of the most useful imaging modalities to evaluate the onset of pneumonia within the patient is chest radiography. The imaging examination is used to interpret the level of symptomatic within the patient suffering from Pneumonia. With Chest radiography, the degree of dyspnoea, level of impairment of carbon monoxide diffusion in lungs (DI, co), the CD4+ cell count in blood and the presence of leukocytosis can be measured for the patient with Community-Acquired Pneumonia (Amatya et al., 2018). Additionally, the importance of imagining in the diagnosis of community-acquired pneumonia is it can enable the physician to detect the pathogen and specific imaging appearances. For example, the pathogen responsible for community-acquired Pneumonia is Streptococcus pneumonia, based on which specific imaging appearance will be alveolar or lobar pneumonia.

Table 1 Imaging findings of the responsible pathogens for community-acquired pneumonia

Table 2: Clinical conditions of different community-acquired Pneumonia by Imaging findings

Community-Acquired Pneumonia

Community-Acquired Pneumonia or CAP can be divided into three distinctive patterns in imaging examination:

Consolidation

the below figure shows the imaging in Chest radiography of pneumonia caused by Streptococcus pneumonia, which shows an alveolar nodule in a man with the disease. The chest radiography shows the nonsegmental consolidation in the right lung with a minor fissure suggestive which indicates the presence of upper lobe pneumonia (Geanacopoulos et al., 2020.).

(Figure 1: Chest radiography image finding for the Pneumonia caused by Streptococcus pneumonia)

Peri-bronchial nodules

in the case of bronchopneumonia, the chest radiography or chest x-ray image shows the reticulonodular opacities and focal consolidation in the lower lung. The x-ray image also shows the enlarged pulmonary hilum in figure 2 which can consider a clear indication of the onset of CAP within a patient. Similarly, figure 3 is an example of another chest x-ray image or image findings through chest radiography (Ippolito et al., 2020.). The image shows the faint nodular opacity in the right middle lung. From the image, it can also be detected that the air valve is narrow and the volume of the left lung is less due to the presence of patchy consolidation and thickening of the pleura. These image findings can be considered as an indication of pneumonia and the existence of old tuberculosis.

(Figure 2: Chest Radiography is showing the reticulated opacities and focal consolidation at left middle lungs, due to the onset of bronchopneumonia)

(Figure 3: The Chest Radiography is showing the nodular opacities in the right middle lungs due to the onset of post-primary tuberculosis)

Ground-glass opacity

the below figure is the Chest Radiography image of Pneumonia caused by Mycoplasma pneumonia. The chest radiography is showing patchy ground-glass opacity or GGO with the presence of peri-bronchial nodules in the middle of the right lungs (Litmanovich et al., 2020).

(Figure 4: Radiography image of pneumonia caused by M. pneumoniae)

Chest radiography is being chosen as one of the common imaging techniques to detect the onset of pneumonia for patients due to low radiation dose, wide accessibility and low cost.

Discussion

CASP TOOL:

The aim or purpose of this assessment is to critically evaluate the evidence that underpins the use of diagnostic tools in clinical practice. In this assessment, therefore, the focus has been given to the use of chest radiography or chest x-ray for the clinical practice of detecting and treating Pneumonia or CAP (Community Acquired Pneumonia). To critically analyse the evidence for highlighting the benefit of using the Chest X-ray as the gold standard for Community-Acquired Pneumonia, five research articles have to be assessed thoroughly. In this section, the CASP tool will be used to assess the research articles.

Analysis

An in-depth analysis of paper 1 showcases the diagnostic accuracy f Chest X-Ray in the detection of community-acquired pneumonia. If this paper is thoroughly analyzed, it can be concluded that Chest X-ray is one of the simplest and most dependable diagnostic tools to detect Community-Acquired Pneumonia or CAP. To ensure the use and benefit of using the Chest X-ray for Pneumonia, the patients are being chosen from the ED or emergency department of Imam Reza Medical Research and Training Hospital, Iran. During the selection of the sample, it was ensured that the patients must be suffered from Pneumonia or suspected Pneumonia and underwent CUS and CXR or Chest X-Ray. Analysis of the result showed imaging findings of 30 patients with clinical suspicion of CAP or community-acquired pneumonia. the sensitivity and specificity of the Chest X-ray in Pneumonia detection among the sample were 93 per cent, where the CI value is 75. 8 to 98.8 and 0.0% respectively. On the main strength of this paper is the comparison between the accuracy and beneficial aspect of using Chest X-ray and ultrasonography or CUS and CT scan in detecting pneumonia. As per the result, the sensitivity of CUS in disease detection was 100%, though the specificity could not be determined by CUS. On the other hand, in comparison to CXR, the reliability of using CT scan to detect Pneumonia is high in accuracy (Taghizadieh et al., 2015).

In the second article, the focus has completely been given to the use of Chest X-rays to detect Pneumonia caused due to novel Coronavirus. Depth analysis of this article shows that a standard chest X-ray can be performed in anteroposterior projection only (Ippolito et al., 2020). This article also showcased that from X-ray images the presence and distribution of parenchymal abnormalities can be detected, which include the presence of alveolar opacities in the lungs of the individual, infected by Sars-CoV-2 virus, presence of reticular opacities or the coarse liner shadow and the pleural effusion. Considering the result of this article, it can be seen that a Chest X-ray has been used to check the overall sensitivity, specificity, NPV, PPV and accuracy of the diagnosis of Pneumonia caused by the SARS-CoV-2 virus. In reference to the accuracy and reliability of using Chest X-Ray to detect Pneumonia or in clinical practice, it can be stated that sensitivity, PPV and NPV values of Chest X-rays showcase a lower value when the symptom appears in less than five days before performing another imaging techniques, whereas the specificity and accuracy value used to be higher in similar circumstances. This indicates that before the development of the disease within the vulnerable individual, the physician can detect the onset of the scenario within the lungs or chest by using the Chest X-ray technique. Additionally, considering this article, it can also be highlighted that by using only Chest radiography, lung appearance can easily be detected (Reali et al., 2014). For example, in case of an infection by SARS-CoV-2, Chest Radiography or Chest X-Ray can provide a clear image of infected lungs, which can be characterized by alveolar or reticular opacities with involvement of bilateral and peripheral lungs. On the other hand, by using the image obtained from the Chest X-ray, the nature of the Pneumonia can also be differentiated. For example, in case of the Pneumonia caused by novel Coronavirus, reticular or alveolar opacities can be observed, whereas no such pattern cannot be seen in patients affected by common or seasonal pneumonia- which also helps to discriminate the origin of the disease.

Considering the third article, it can be stated that imaging examination specifically the CT scan is more suggestive to detect any specific pathogens. The Imaging examination is considered to be indispensable to managing the CAP, and the primary role of the tool is to confirm the diagnosis of Pneumonia (Nambu et al., 2014). By using the Chest X-ray or Chest radiography, professionals can easily characterize the nature of pneumonia, as the image obtained from the x-ray provide a clear overview of the pathophysiological conditions and specific imaging appearances which in turn can be used as a discriminator for community-acquired pneumonia.

Depth analysis of the fourth article helped to understand that Chest radiography is ideal to use for the clinical characterization of patients with pneumonia. With images obtained from Chest radiography, a thorough comparison between the patients with infiltration of Pneumonia can be carried out based on several clinical factors (Kitazawa et al., 2020). Those clinical factors are age, sex, BMI, CRP level, Laterality, and so on. Additionally, by using chest radiography, a comparison between the pneumonia pathogens can also be carried out which add value to the treatment and prevention of the disease and clinical practice.

The last article has been selected to differentiate the usefulness of Chest X-ray over Lungs Ultrasound. Lungs Ultrasound is another diagnostic tool to detect the onset of Pneumonia. This paper contradicts the other research overviews, by shedding light on the increased accuracy of Ultrasound over the use of Chest X-Ray or CXR (Ticinesi et al., 2016). Lung Ultrasound offers higher sensitivity for the diagnosis of pneumonia compared to the chest X-ray.

Conclusion

This assessment is aiming to critically evaluate the evidence that underpins the use of any diagnostic tool in clinical practice. In this essay, therefore, the focus has been given to the use of chest radiography to detect Pneumonia or more specifically, community-acquired pneumonia. In this essay, five articles and research journals are thoroughly assessed, which underpin the fact that Chest radiography is one of the common tools used for the diagnosis of Pneumonia. A systematic review of the literature showed that community-acquired pneumonia is one of the common conditions associated with morbidity and it can be suppressed by early recognition of a number of international guidelines are recommended about the use of chest radiography or chest x-ray. According to Feldman, one of the initial considerations to optimal manage the onset or outspread of CAP is to confirm the diagnosis and chest radiography is universally considered the gold standard. It is an inexpensive procedure and the only way to determine the nature of Pneumonia by detecting the imaging appearance of the lesion in the lungs. Though, several research articles are being discussed in this assessment, that contradict the fact that Lung ultrasound is more accurate with high sensitivity and specificity in comparison to chest radiography when it comes to early detection of Pneumonia.

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