American College of Radiology
ACR Appropriateness Criteria®

Chronic Dyspnea-Noncardiovascular Origin

Variant 1: Chronic dyspnea. Unclear etiology. 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 0 0 0 0 13
References Study Quality
2 (15864893) 4
3 (22962929) 4
7 (21215608) 2
11 (2802893) 3
CT chest without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 2 3 3 2 2 0 0
References Study Quality
8 (1535900) 4
12 (8153310) 2
13 (25447621) 3
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 3 2 3 5 0 0 0 0
References Study Quality
8 (1535900) 4
12 (8153310) 2
13 (25447621) 3
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 1 0 2 0 0 0 0
References Study Quality
8 (1535900) 4
12 (8153310) 2
13 (25447621) 3
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 1 0 1 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 8 3 0 0 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 10 3 0 0 0 0 0 0 0
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 5 0 1 0 0 0 0 0
Variant 2: Chronic dyspnea. Suspected chronic obstructive pulmonary disease (COPD). 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 0 0 1 1 11
References Study Quality
14 (11194777) 4
15 (19631518) 4
CT chest without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 1 5 4 1 1 0
References Study Quality
16 (25961632) 4
17 (26098755) 2
18 (23220894) 2
19 (25442794) 3
20 (24710855) 3
21 (18351420) 3
22 (25474145) 3
23 (24703520) 3
24 (24334816) 2
25 (22514236) 3
26 (27776670) 3
27 (19938970) 3
28 (25844673) 3
29 (22016483) 2
30 (16537852) 3
CT chest with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 3 5 2 1 0 0 0
References Study Quality
16 (25961632) 4
17 (26098755) 2
18 (23220894) 2
19 (25442794) 3
20 (24710855) 3
21 (18351420) 3
22 (25474145) 3
23 (24703520) 3
24 (24334816) 2
25 (22514236) 3
26 (27776670) 3
27 (19938970) 3
28 (25844673) 3
29 (22016483) 2
30 (16537852) 3
MRI chest without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 6 2 1 1 3 0 0 0 0
References Study Quality
31 (26744928) 3
32 (21392914) 2
33 (25575114) 3
MRI chest without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 6 1 3 0 3 0 0 0 0
References Study Quality
31 (26744928) 3
32 (21392914) 2
33 (25575114) 3
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 3 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 1 1 0 0 0 1 0
References Study Quality
16 (25961632) 4
17 (26098755) 2
18 (23220894) 2
19 (25442794) 3
20 (24710855) 3
21 (18351420) 3
22 (25474145) 3
23 (24703520) 3
24 (24334816) 2
25 (22514236) 3
26 (27776670) 3
27 (19938970) 3
28 (25844673) 3
29 (22016483) 2
30 (16537852) 3
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 9 4 0 0 0 0 0 0 0
Variant 3: Chronic dyspnea. Suspected central airways disease. 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 0 0 1 4 8
References Study Quality
34 (24297576) 2
35 (22760718) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 1 1 4 5 1
References Study Quality
36 (26102379) 4
37 (17527116) 3
38 (17356090) 3
39 (24361144) 3
40 (17913426) 3
41 (20591697) 3
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 1 1 5 4 1 0 0
References Study Quality
36 (26102379) 4
37 (17527116) 3
38 (17356090) 3
39 (24361144) 3
40 (17913426) 3
41 (20591697) 3
MRI chest without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 3 0 5 3 1 0 0 0
References Study Quality
42 (23086288) 1
43 (28796542) 2
44 (28199136) 4
45 (16941092) 4
MRI chest without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 3 0 5 3 1 0 0 0
References Study Quality
42 (23086288) 1
43 (28796542) 2
44 (28199136) 4
45 (16941092) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 2 0 0 0 0 0 0
References Study Quality
36 (26102379) 4
37 (17527116) 3
38 (17356090) 3
39 (24361144) 3
40 (17913426) 3
41 (20591697) 3
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 9 3 1 0 0 0 0 0 0
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 5 1 0 0 0 0 0 0
References Study Quality
46 (23966375) 2
Variant 4: Chronic dyspnea. Suspected interstitial lung disease. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 3 1 2 7
References Study Quality
48 (24481766) 4
49 (19926869) 3
50 (2717730) 2
51 (15878493) 2
52 (3797650) 2
53 (1620845) 3
54 (25317858) 3
55 (18982210) 4
56 (18806139) 4
57 (26571061) 2
58 (15256390) 3
59 (18057059) 1
60 (23220902) 3
61 (21926853) 3
62 (20622689) 2
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 2 3 8
References Study Quality
47 (642974) 4
CT chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 1 0 3 3 3 1 0 0
References Study Quality
48 (24481766) 4
49 (19926869) 3
50 (2717730) 2
51 (15878493) 2
52 (3797650) 2
53 (1620845) 3
54 (25317858) 3
55 (18982210) 4
56 (18806139) 4
57 (26571061) 2
58 (15256390) 3
59 (18057059) 1
61 (21926853) 3
62 (20622689) 2
60 (23220902) 3
MRI chest without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 5 4 2 1 0 0 1 0 0
References Study Quality
63 (23523024) 2
64 (24355658) 2
65 (18356432) 2
66 (25871501) 2
MRI chest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 5 5 1 1 0 0 1 0 0
References Study Quality
63 (23523024) 2
64 (24355658) 2
65 (18356432) 2
66 (25871501) 2
US chest Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 2 1 3 1 0 0 0 0
References Study Quality
72 (22589373) 2
73 (24791173) 3
74 (-3123437) 3
75 (26494471) 3
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 1 0 1 0 0 0 0
References Study Quality
48 (24481766) 4
49 (19926869) 3
50 (2717730) 2
51 (15878493) 2
52 (3797650) 2
53 (1620845) 3
54 (25317858) 3
55 (18982210) 4
56 (18806139) 4
57 (26571061) 2
58 (15256390) 3
59 (18057059) 1
60 (23220902) 3
61 (21926853) 3
62 (20622689) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 1 0 1 3 0 0 0 0
References Study Quality
10 (27581824) 4
67 (21242947) 2
68 (23900129) 4
69 (19289428) 3
70 (27842667) 2
71 (27339874) 3
Variant 5: Chronic dyspnea. Suspected disease of the pleura or chest wall. 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] 8 8 0 0 0 0 0 1 1 5 6
References Study Quality
76 (8796649) 3
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 0 1 4 5 1 1
References Study Quality
77 (9017800) 4
78 (25077699) 4
79 (26076488) 2
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 2 3 4 2 1
References Study Quality
77 (9017800) 4
78 (25077699) 4
79 (26076488) 2
MRI chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 8 0 1 1 0
References Study Quality
80 (2028857) 4
81 (26502346) 2
82 (26214770) 3
MRI chest without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 1 1 5 2 2 1 0
References Study Quality
80 (2028857) 4
81 (26502346) 2
82 (26214770) 3
US chest May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 6 1 0 1 0 4 3 2 2 0
References Study Quality
83 (27613540) 3
84 (-3123448) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 5 3 3 1 1 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 3 2 0 1 0 0 0 0
References Study Quality
77 (9017800) 4
78 (25077699) 4
79 (26076488) 2
Variant 6: Chronic dyspnea. Suspected diaphragm dysfunction. 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 1 9
References Study Quality
85 (17368210) 2
Fluoroscopy chest Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 1 0 0 1 0 1 0 4 6
References Study Quality
86 (22411950) 4
87 (23778774) 2
MRI chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 5 2 0 1 0
References Study Quality
88 (17145404) 3
89 (27391236) 3
MRI chest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 6 1 0 1 0
References Study Quality
88 (17145404) 3
89 (27391236) 3
US chest May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 5 5 1 0 0
References Study Quality
90 (24211983) 3
91 (23382111) 4
92 (25165390) 2
93 (26994409) 2
94 (23110443) 3
95 (27701744) 3
96 (24700122) 3
97 (26620221) 2
98 (26357011) 3
99 (25971723) 2
100 (27167428) 3
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 0 5 1 3 1 1 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 8 0 0 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 8 3 1 0 1 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.