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Appropriateness Criteria

Variant 1: Adult. Acute respiratory illness in immunocompetent patients with negative physical examination, normal vital signs, and no other risk factors for poor outcome. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest May be appropriate (Disagreement) Expert Opinion ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 0 0 1 2 5 3 2 1 3
References Study Quality
15 (16635092) 4
13 (7455106) 4
14 (3718128) 3
11 (17412152) 2
10 (25785179) 2
18 (27793503) 2
17 (-3198008) 4
16 (17278083) 4
US chest Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 4 2 0 0 0 0 0 0
References Study Quality
19 (24184011) 3
20 (21030550) 2
21 (25758182) 2
22 (22700780) 3
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 0 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 1 0 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 3 2 2 1 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 1 0 1 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 3 0 1 1 1 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 1 0 1 2 0 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 2 1 0 0 1 0 0
Variant 2: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, or abnormal vital signs, or organic brain disease, or other risk factors for poor outcome. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 0 0 0 0 1 4 12
References Study Quality
15 (16635092) 4
16 (17278083) 4
13 (7455106) 4
14 (3718128) 3
29 (16837505) 3
27 (17099198) 4
28 (15336579) 4
11 (17412152) 2
10 (25785179) 2
30 (33124905) 4
18 (27793503) 2
US chest Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 8 6 2 1 0 0 0 0 0
References Study Quality
19 (24184011) 3
22 (22700780) 3
31 (34515247) 2
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 1 0 0 0 0 0 1
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 2 0 0 1 0 1 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 9 1 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 2 1 1 1 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 2 7 2 1 0 0 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 6 4 0 0 0 0 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 2 0 0 0 1 0 0 0
Variant 3: Adult. Acute respiratory illness in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors and negative or indeterminate initial chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 1 0 0 1 3 4 5 4
References Study Quality
16 (17278083) 4
32 (18571356) 4
35 (26935360) 2
40 (26168322) 3
37 (25083953) 3
39 (32770367) 2
38 (27103390) 4
36 (22498759) 2
34 (23083885) 3
31 (34515247) 2
30 (33124905) 4
12 (32729811) 4
8 (31685101) 4
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 0 0 7 3 7
References Study Quality
16 (17278083) 4
32 (18571356) 4
35 (26935360) 2
40 (26168322) 3
37 (25083953) 3
34 (23083885) 3
31 (34515247) 2
30 (33124905) 4
12 (32729811) 4
CTA chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 3 9 3 1 0 0
US chest Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 7 5 3 2 0 0 0 0 0
References Study Quality
19 (24184011) 3
21 (25758182) 2
22 (22700780) 3
54 (17316468) 4
53 (33635443) 2
52 (33806432) 1
30 (33124905) 4
20 (21030550) 2
9 (20731700) 2
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 2 3 2 2 0 1 0 0
References Study Quality
41 (34037828) 4
50 (21105134) 4
51 (18519226) 4
MRI chest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 9 5 3 0 0 0 0 0 0
References Study Quality
43 (27811069) 1
49 (32491257) 2
48 (21816896) 3
47 (26546472) 2
46 (17943326) 2
45 (18726093) 4
44 (24189389) 1
42 (27641778) 2
41 (34037828) 4
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 4 1 0 0 0 1 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 2 0 0 0 0 0 0
Variant 4: Adult. Acute respiratory illness in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 1 1 0 0 1 2 5 8
References Study Quality
55 (7384467) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 1 3 4 3 3 3
References Study Quality
55 (7384467) 4
US chest May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 5 8 1 1 1 0
References Study Quality
58 (26218493) 4
22 (22700780) 3
54 (17316468) 4
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 8 2 2 0 0 0 0 0
References Study Quality
41 (34037828) 4
50 (21105134) 4
57 (2312846) 2
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 2 4 2 4 0 1 1 0
References Study Quality
41 (34037828) 4
50 (21105134) 4
57 (2312846) 2
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 3 1 0 1 0 0 1
CTA chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 6 3 1 0 0 0 0
References Study Quality
56 (29916720) 2
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 2 0 0 1 0 0 0
Variant 5: Adult. Acute asthma exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest May be appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 6 6 0 0 0 2 6 4 3 0 2
References Study Quality
59 (7297142) 4
14 (3718128) 3
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 1 0 0 2 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 0 0 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 2 0 0 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 3 2 0 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 2 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 3 1 2 1 1 0 1 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 1 2 1 0 0 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 2 0 0 0 1 0 0
Variant 6: Adult. Acute asthma exacerbation in immunocompetent patients, complicated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 1 0 0 1 1 3 11
References Study Quality
59 (7297142) 4
14 (3718128) 3
62 (7237908) 3
61 (2060333) 4
US chest Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 9 6 2 0 0 0 0 0 0
References Study Quality
19 (24184011) 3
20 (21030550) 2
21 (25758182) 2
22 (22700780) 3
9 (20731700) 2
54 (17316468) 4
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 2 0 0 0 0 1 1
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 4 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 10 1 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 1 3 1 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 5 3 1 2 1 0 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 2 0 3 0 1 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 2 0 0 0 1 0 0
Variant 7: Adult. Acute COPD exacerbation in immunocompetent patients, uncomplicated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 1 0 1 0 2 3 10
References Study Quality
65 (2818109) 4
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 0 1 1 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 2 0 0 0 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 2 0 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 6 2 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 2 1 0 1 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 8 2 0 0 0 0 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 3 3 0 2 1 1 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 2 0 0 0 1 0 0
Variant 8: Adult. Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, or fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 1 0 1 0 2 3 10
References Study Quality
65 (2818109) 4
CTA chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 4 3 6 2 0 0 0
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 1 3 1 0 1 0 1 0
References Study Quality
21 (25758182) 2
22 (22700780) 3
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 2 1 0 0 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 2 0 0 0 0 1
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 6 4 1 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 1 2 0 0 1 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 3 3 1 1 0 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 9 6 2 0 0 0 0 0 0
Variant 9: Adult. Acute respiratory illness in immunocompetent patients with suspected pneumonia on initial imaging. Follow-up imaging to ensure resolution.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 1 0 0 0 1 1 4 2 9
References Study Quality
75 (23222200) 2
74 (21518934) 2
73 (20102994) 2
72 (31573350) 4
71 (7963634) 4
70 (8460356) 2
69 (25583286) 2
68 (24370128) 4
CT chest with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 2 10 4 0 0 0
References Study Quality
69 (25583286) 2
68 (24370128) 4
67 (25531242) 2
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 0 11 4 1 0 0
References Study Quality
67 (25531242) 2
68 (24370128) 4
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 2 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 1 0 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 0 0 1 1 0 0 1
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 2 2 0 1 0 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 1 2 2 0 0 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 1 0 0 0 0 1 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.