CXR needed? (Adults)
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SOBREATH
☐(S) Oxygen Saturation <90%
☐(O) Older than 59 years
☐(B) Breath sounds decreased
☐(R) Rales or Resp Rate>24/min
☐(E) Embolic disease (prior DVT/PE)
☐(A) Alcohol abuse
☐(T) Tuberculosis or Temp>=38°C
☐(H) Hemoptysis
Patient chief complaint Chest pain Shortness of breath Cough or Fever Other
R e s u l t s
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CXR
 
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CXR needed? (Adults)
These recommendations are for when to obtain a chest radiograph in atraumatic adult emergency department patients.

The mnemonic SOBREATH is used:


(S) Oxygen Saturation <90%
(O) Older than 59 years
(B) Breath sounds decreased
(R) Rales or Resp Rate>24/min
(E) Embolic disease (prior DVT/PE)
(A) Alcohol abuse
(T) Tuberculosis or Temp >=38°C (100.4°F)
(H) Hemoptysis.
If any of these items are present, chest radiograph may be indicated and expected to have high yield.
Summary of the data:
1650 consecutive adult patients at an urban emergency department, who underwent chest radiographs (CXR) for atraumatic complaints made up the study group. Among this group, 840 had normal CXR's, 284 and clinically significant abnormal CXR's and 526 had clinically insignificant abnormal CXR's.
Among those with abnormal radiographs:
  • 40% Pneumonia
  • 30% CHF
  • 4% ischemic heart disease
  • 3.5% tuberculosis
  • 2% pleural effusion
  • 1.4% pneumoperitoneum
  • 0.7% pneumothorax or Pneumomediastinum
  • 6.7% other medical diagnoses
The assessement, is that if the "SOB" criteria had been applied in this population; 558 chest radiographs would not have been performed, with the cost of missing 13 clinically significant abnormalities (6 cases of CHF, 5 pneumonias, 2 lung cancers).
Negative predictive value was 98%
Positive predictive value was 25%
Sensitivity was 95%
Specificity was 40%

Depending upon the chief complaint of the patient that led to consideration of a chest radiograph, the sensitivity and specificity of applying this algorithm was impacted.

Patient Chief Complaint==>Sensitivity of SOB algorithm==>Specificity of SOB algorithm

  • All patients==>95%==>40%
  • Chest pain==>84%==>57%
  • Shortness of breath==>98%==>26%
  • Cough or fever==>98%==>18%
Consideration of relying on this algorithm for shortness of breath or cough/fever presentations is more reasonable than in patients with chest pain, where the sensitivity is lower (expect a 16% missed diagnosis rate).

Reference:

Rothrock SG, Green SM, et al. High yield criteria for obtaining non-trauma chest radiography in the adult emergency department population. J Emerg Med. 2002 Aug;23(2):117-24.