Daily Routine Chest Radiographs

Abstract

I read with interest the report by Krivopal and coworkers (May 2003)1Krivopal M Shlobin OA Schwartzstein RM Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.Chest. 2003; : 1607-1614Abstract Full Text Full Text PDF Scopus (85) Google Scholar on the utility of daily routine portable chest radiographs in mechanically ventilated patients in a medical ICU. Krivopal et al showed that a strategy using daily routine chest radiographs, compared with a restrictive strategy in which radiographs are obtained based only on clinical indications, was not associated with better outcome. Although the advantage of a restrictive strategy was not as large as I expected,2Price MB Grant MJ Welkie K Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit.Crit Care Med. 1999; 27: 1588-1593Crossref PubMed Scopus (43) Google Scholar this report significantly contributes to the discussion between the two different schools of thought regarding the utility of obtaining daily chest radiographs in critically ill patients. Unfortunately, the investigators excluded patients who had been intubated for > 72 h (ie, patients who had been transferred from another hospital). This is part of my concern. In my institution, these patients, especially, are the ones with complex diseases and are probably those in whom it would be most interesting to see whether a restrictive strategy is as safe as a strategy in which daily routine chest radiographs are made. I was very much surprised to see that the absolute number of radiographs prompting an intervention was larger in the restrictive-strategy group. This can only be the case when the number of “radiologic events” was higher in the last group of patients. In the discussion, it is claimed that this might be the result of a difference in the number of patients (approximately 15%, not 25%, as claimed by the authors) and in case mix, but I strongly disagree that these are the only explanations. Since this was an unblinded study, giving more attention to the radiographs by individual physicians may very well have caused this difference. Although the investigators claim that a restrictive strategy is cheaper (226 vs 293 radiographs), this needs more exploration. Were all radiology tests taken into account? I can imagine that when more radiologic events are seen, as was the case in the restrictive-strategy group, more radiology tests, such as CT scanning can or will be used. One or two transports to the CT scan ward may cause the advantage of fewer chest radiographs to be unimportant. Daily Routine Chest RadiographsCHESTVol. 125Issue 3PreviewI read the article by Krivopal et al1 with interest but was disappointed that they omitted references to my two previous articles on this subject. In comparing the utility of daily “routine vs clinically indicated” portable radiographs of the chest in ventilated medical ICU patients, they found that studies ordered with a clinical indication had a higher score for both diagnostic and therapeutic efficacy, and that there was no difference in the health outcomes for the two groups. Our results shed a different light on the subject, and I would like to share them with you. Full-Text PDF