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Appropriateness Criteria

Variant 1: Recent pneumonia with suspected parapneumonic effusion or empyema. 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] 8 8 0 0 0 0 0 1 3 3 6
References Study Quality
28 (21651642) 2
29 (27613540) 3
27 (27793503) 2
26 (17278083) 4
25 (9356004) 4
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 0 2 5 5
References Study Quality
18 (21622586) 2
20 (-3195839) 4
19 (21159803) 1
17 (26076488) 2
16 (28370693) 2
15 (33820639) 2
14 (35049844) 4
13 (28274565) 4
US chest May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 2 0 2 2 1 4 2 0
References Study Quality
36 (19933660) 3
35 (11762545) 2
34 (30675767) 2
33 (27709281) 3
32 (19616366) 2
31 (11127008) 2
30 (33033148) 4
29 (27613540) 3
13 (28274565) 4
CT chest without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 0 3 5 3 0 1 0 0
References Study Quality
18 (21622586) 2
14 (35049844) 4
16 (28370693) 2
17 (26076488) 2
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 1 1 2 3 1 0 0 0
References Study Quality
24 (21364472) 4
23 (32191736) 2
22 (33963675) 2
21 (28931146) 4
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 1 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 11 0 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 6 5 2 0 0 0 0 0 0
Variant 2: Recent minor blunt trauma with suspected pleural effusion. 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] 8 8 0 0 0 0 0 0 5 2 6
References Study Quality
46 (15082295) 2
47 (24626118) 2
49 (29433802) Good
40 (30287121) 2
39 (28130347) 4
50 (31179075) 1
CT chest with IV contrast Usually appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 1 0 0 1 0 4 4 3
References Study Quality
40 (30287121) 2
39 (28130347) 4
38 (26169926) 3
US chest May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 2 0 4 2 2 2 0
References Study Quality
30 (33033148) 4
49 (29433802) Good
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 1 6 3 0 1 0 0
References Study Quality
41 (-3195840) 2
CTA chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 2 0 1 1 0 1 7 0
References Study Quality
44 (27299139) Good
43 (26440607) 1
42 (21045745) 2
Image-guided aspiration chest Usually not appropriate Expert Consensus Varies Varies 1 1 10 2 1 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 1 2 0 2 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 0 1 2 1 1 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 2 0 0 0 0 0 0
Variant 3: Dyspnea, cough, or chest pain with suspected pleural effusion, noninfectious. 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 0 0 0 0 1 0 2 3 7
References Study Quality
7 (20696692) 4
59 (34447992) 4
60 (25572643) 2
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 2 2 3 6 0
References Study Quality
19 (21159803) 1
50 (31179075) 1
53 (28025056) 2
52 (30406935) 4
US chest May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 2 2 1 5 1 1 1 0
References Study Quality
32 (19616366) 2
63 (33721865) 2
64 (-3195841) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 1 1 3 5 1 0 0 0
References Study Quality
54 (25881595) 2
55 (26150676) 4
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 7 1 1 3 1 0 0 0 0
References Study Quality
58 (30044259) 2
57 (27423676) 3
60 (25572643) 2
59 (34447992) 4
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 0 1 4 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 10 1 1 1 0 0 0 0 0
CTA chest with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 3 1 1 5 0 0 0 0
References Study Quality
56 (17298456) 2
58 (30044259) 2
57 (27423676) 3
Variant 4: Pleural effusion incidentally detected on incomplete thoracic imaging study. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US chest May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 3 3 1 0 3 2 1 0 0
Radiography chest May be appropriate (Disagreement) Expert Opinion ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 2 1 1 2 5 1 0 0 1
CT chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 2 1 5 1 0 2 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 2 0 3 0 1 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 0 0 3 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 10 2 1 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 2 2 3 0 1 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 3 0 0 0 0 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.