Daily Routine Chest Radiographs Research Articles

The Importance of Daily Routine Chest Radiography in Mechanically Ventilated Children

Objective: To asses the usefulness of daily routine chest radiography in mechanically ventilated children. Methods: This retrospective study was conducted in a pediatric intensive care unit at Queen Rania Al-Abdullah Hospital for children during the period between February 1 and April 30, 2010. The chest radiographs of 25 patients who had been mechanically ventilated during the study period were reviewed using the picture archiving and communication system. Results: Of the 25 patients, 13 (52 %) were males and 12 (48 %) were females. The age ranged between 1 day and 14 years of life. 245 chest radiographs were evaluated by a pediatric intensivist. 23 % of all radiographs showed cardiopulmonary abnormalities, 12 % showed malpositioned endotracheal tubes and 9 % malpositioned central venous catheter. 14% of chest radiographs had findings that altered management. The most frequent management changes done were repositioning of central venous catheters, and changes in drug therapy. Conclusion: We conclude that the daily routine chest radiography in mechanically ventilated children had diagnostic and clinical usefulness.

EComment. Daily routine chest radiographs after pulmonary surgery

We read with great interest the paper by Reeb et al. [1] regarding the utility of daily routine (DR) chest radiographs following pulmonary surgery. They concluded that the on-demand (OD) strategy of obtaining chest X-rays only when clinically indicated, led to equivalent outcomes while reducing radiation exposure and cost of care. Rather than completely do away with DR chest X-rays, it would be interesting to try and identify subgroups of patients who may benefit from this strategy. Earlier studies suggested that pulmonary or unstable cardiac patients, and patients with pulmonary artery catheters, needed daily X-ray monitoring. The American College of Radiology (ACR) previously recommended DR chest radiographs for patients with acute cardiopulmonary problems and those on mechanical ventilation. They have since revised the ACR Appropriateness Criteria in 2011, to favour the more selective OD approach [2]. Cerfolio et al. have found that DR chest X-rays are warranted in post-thoracotomy patients who are hypoxic [1]. In this sub-group, 79% of patients had a radiological finding that influenced their care. Oba et al. [3] however, were not able to identify any sub-population of critically ill patients, who would benefit from DR chest X-rays. The OD strategy has slowly gained acceptance in clinical practice. Graat et al. [4] reported in 2006, that although intensivists doubted the value of DR chest radiography, they were still reluctant to change their practice. More recently, the RadioDay study [5] found that two-thirds of French intensive care units had moved over to ordering chest X-rays on an OD basis. The hesitation to abandon the traditional approach may be related to the comfort level of the intensive care team, and the objectivity of a chest X-ray from a clinical and medico-legal standpoint. Another caveat is, that patients will have to be more closely monitored for changes in their cardiopulmonary status for the OD approach to be successful. Pending the results of further studies, the most efficient plan for utilization of resources may have to be tailored to each individual patient in order to achieve the best outcome. Conflict of interest: none declared.

EComment. Chest sonography could reduce routine chest radiographs after pulmonary surgery

We read with interest the well-written best evidence topic by Reeb and colleagues, about the use of daily routine chest radiographs as compared to on-demand strategy after pulmonary surgery [1]. authors concluded that daily radiographs could be foregone, because the on-demand strategy has a better impact on management and has not proven to negatively affect outcomes, even if prospective and randomized trials are necessary to improve the current level of evidence. We would like to add some comment on this important topic. In their overview, the authors listed the important prospective study by Cerfolio and Bryant [2]. In his related commentary [3], Michael Lanuti wrote: The authors observed that chest roentgenograms changed clinical management in 72% (49 of 62) of patients exhibiting hypoxia during their hospitalization, thus justifying the need for chest radiography. In contrast, only 27% (268 of 975) of patients required an alteration in clinical management in the absence of hypoxia. […] One could argue that because a chest roentgenogram changed clinical management in nonhypoxic patients nearly one third (27%) of the time, daily chest radiography remains beneficial. According to these data, Lanuti suggested to start a simple prospective randomized controlled trial to improve the level of evidence. Recently, Goudie and colleagues evaluated chest sonography in postoperative care, and found it to be a possibility to reduce the number of chest radiographs [4]. conclusion of this prospective trial was that chest sonography is an effective, convenient, inexpensive and easy to learn tool in the postoperative management of thoracic surgery patients. In our opinion, the use of chest sonography could be an alternative way to promote a reduction of postoperative chest radiographs, without the risk of delaying a change in management. Today, cost saving is an important goal, but it would be better to save money without sacrificing quality or reducing safety: according to the IDEAL recommendations [5], we believe that any change in postoperative management of surgical patients should be evaluated with the best possible evidence. Conflict of interest: none declared.

Are daily routine chest radiographs necessary after pulmonary surgery in adult patients?: Table 1:

A best evidence topic was constructed according to a structured protocol. The question addressed was whether daily routine (DR) chest radiographs (CXRs) are necessary after pulmonary surgery in adult patients. Of the 66 papers found using a report search, seven presented the best evidence to answer the clinical question. Four of these seven studies specifically addressed post-cardiothoracic adult patients. Three of these seven studies addressed intensive care unit (ICU) patients and included post-cardiothoracic adult patients in well-designed studies. Six of these seven studies compared the DR CXRs strategy to the clinically indicated, on-demand (OD) CXRs strategy. Another study analysed the clinical impact of ceasing to perform the DR, postoperative, post-chest tubes removal CXRs. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, the seven studies are unanimously in favour of forgoing DR CXRs after lung resection and advocate OD CXRs. One study suggested that hypoxic patients could benefit from a DR CXRs strategy, while other studies failed to identify any subgroup for whom performing DR CXRs was beneficial. Indeed, DR CXRs, commonly taken after thoracic surgery, have poor diagnostic and therapeutic value. Eliminating them for adult patients having undergone thoracic surgery significantly decreases the number of CXRs per patient without increasing mortality rates, length of hospital stays (LOSs), readmission rates and adverse events. Hence, current evidence shows that DR CXRs could be forgone after lung resection because OD CXRs, recommended by clinical monitoring, have a better impact on management and have not been proved to negatively affect patient outcomes. Moreover, an OD CXRs strategy lowers the cost of care. Nevertheless, an OD CXRs strategy requires close clinical monitoring by experienced surgeons and dedicated intensivists. However, given the published studies' low level of evidence, prospective and randomized trials, specifically after thoracic surgery, are necessary in order to confirm these results.

ACR Appropriateness Criteria Routine Chest Radiographs in Intensive Care Unit Patients

Daily routine chest radiographs in the intensive care unit (ICU) have been a tradition for many years. Anecdotal reports of misplacement of life support items, acute lung processes, and extra pulmonary air collections in a small number of patients served as a justification for routine chest radiographs in the ICU. Having analyzed this practice, the ACR Appropriateness Criteria Expert Panel on Thoracic Imaging has made the following recommendations: • When monitoring a stable patient or a patient on mechanical ventilation in the ICU, a portable chest radiograph is appropriate for clinical indications only. • It is appropriate to obtain a chest radiograph after placement of an endotracheal tube, central venous line, Swan-Ganz catheter, nasogastric tube, feeding tube, or chest tube. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The strongest data contributing to these recommendations were derived from a meta-analysis of 8 trials comprising 7,078 ICU patients by Oba and Zaza [1].

Routine chest radiographs in the surgical intensive care unit: Can we change clinical habits with no proven benefit?

Daily routine chest radiographs (CR) are commonly performed in surgical ICU. Unnecessary CR increase costs and expose the staff and the patients to radiation risk. The goal of our study was to estimate the value of daily routine CR in the ICU and to determine the correlation between CR and physical findings in surgical ICU patients. Prospective observational study was conducted during period of two months at the ICU department at the Clinic for Digestive Surgery, Clinical Center of Serbia, Belgrade. It included 97 consecutive patients who underwent digestive surgery and stayed at the ICU for at least two days. During their ICU stay, CRs were obtained as a clinical routine or to monitor lung pathology. Patients were followed daily, and CRs (as the proportion of positive findings) were compared with physical examination and clinical presentation. A total of 717 CRs were obtained, median number per patient was 4.0 (2.0-7.0). Proportion of positive findings was significantly higher comparing to auscultation until the sixth day of ICU stay. There was no difference in CR findings from day to day after the sixth day. Therapeutic efficacy of CRs was low as only 56 (7.8%) resulted in a change of patient management. We conclude that daily routine CRs are justified in the first six days of ICU stay, and after that time they show no advantages over clinical examination.

Abandoning Daily Routine Chest Radiography in the Intensive Care Unit: Meta-Analysis

Abandoning Daily Routine Chest Radiography in the Intensive Care Unit: Meta-Analysis

Abandoning Daily Routine Chest Radiography in the Intensive Care Unit: Meta-Analysis

To systematically examine whether abandoning daily routine chest radiography would adversely affect outcomes, such as mortality and length of stay (LOS), and identify a subgroup in which daily routine chest radiography might be beneficial. This was a meta-analysis of clinical trials that examined the effect of abandoning daily routine chest radiography in adults in intensive care units (ICUs). Studies were identified through searches of MEDLINE, Cochrane Database, Database of Abstracts of Reviews of Effects, Biological Abstracts, and CINAHL. The results were expressed as odds ratios (ORs) or weighted mean difference (WMD) along with their 95% confidence intervals (CIs). Eight studies with a total of 7078 patients were identified. A pooled analysis revealed that the elimination of daily routine chest radiography did not affect either hospital or ICU mortality (OR, 1.02;[95% CI: 0.89, 1.17; P = .78 and OR, 0.92; 95% CI: 0.76, 1.11; P = .4, respectively). There was no significant difference in ICU LOS (WMD = 0.19 days; 95% CI: -0.13, 0.51; P = .25), hospital LOS (WMD = -0.29 days; 95% CI: -0.71, 0.13; P = .18), and ventilator days (WMD = 0.33 days; 95% CI: -0.12, 0.78; P = .15) between the on-demand and daily routine groups. Regression analyses failed to identify any subgroup in which performing daily routine chest radiography was beneficial. Systematic but unselective daily routine chest radiography can likely be eliminated without increasing adverse outcomes in adult patients in ICUs. Further studies are necessary to identify the specific patient population that would benefit from daily routine chest radiographs.

On-demand Rather than Daily-routine Chest Radiography Prescription May Change Neither the Number Nor the Impact of Chest Computed Tomography and Ultrasound Studies in a Multidisciplinary Intensive Care Unit

On-demand Rather than Daily-routine Chest Radiography Prescription May Change Neither the Number Nor the Impact of Chest Computed Tomography and Ultrasound Studies in a Multidisciplinary Intensive Care Unit

On-demand Rather than Daily-routine Chest Radiography Prescription May Change Neither the Number Nor the Impact of Chest Computed Tomography and Ultrasound Studies in a Multidisciplinary Intensive Care Unit

On-demand Rather than Daily-routine Chest Radiography Prescription May Change Neither the Number Nor the Impact of Chest Computed Tomography and Ultrasound Studies in a Multidisciplinary Intensive Care Unit

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients

On-demand Rather than Daily-routine Chest Radiography Prescription May Change Neither the Number Nor the Impact of Chest Computed Tomography and Ultrasound Studies in a Multidisciplinary Intensive Care Unit

Elimination of daily-routine chest radiographs (CXRs) may influence chest computed tomography (CT) and ultrasound practice in critically ill patients. This was a retrospective cohort study including all patients admitted to a university-affiliated intensive care unit during two consecutive periods of 5 months, one before and one after elimination of daily-routine CXR. Chest CT and ultrasound studies were identified retrospectively by using the radiology department information system. Indications for and the diagnostic/therapeutic yield of chest CT and ultrasound studies were collected. Elimination of daily-routine CXR resulted in a decrease of CXRs per patient day from 1.1 +/- 0.3 to 0.6 +/- 0.4 (P < 0.05). Elimination did not affect duration of stay or mortality rates. Neither the number of chest CT studies nor the ratio of chest CT studies per patient day changed with the intervention: Before elimination of daily-routine CXR, 52 chest CT studies were obtained from 747 patients; after elimination, 54 CT studies were obtained from 743 patients. Similarly, chest ultrasound practice was not affected by the change of CXR strategy: Before and after elimination, 21 and 27 chest ultrasound studies were performed, respectively. Also, timing of chest CT and ultrasound studies was not different between the two study periods. During the two periods, 40 of 106 chest CT studies (38%) and 18 of 48 chest ultrasound studies (38%) resulted in a change in therapy. The combined therapeutic yield of chest CT and ultrasound studies did not change with elimination of daily-routine CXR. Elimination of daily-routine CXRs may not affect chest CT and ultrasound practice in a multidisciplinary intensive care unit.

Low Value of Routine Chest Radiographs in a Mixed Medical-Surgical ICU

To determine the diagnostic efficacy (DE) and therapeutic efficacy (TE) of daily routine chest radiographs (CXRs), and to establish the impact of abandoning this CXR from daily practice on total CXR volume, ICU length of stay (LOS), readmission rate, and ICU mortality. Prospective controlled study in two parts. The first part comprised a 1-year period during which attending physicians were blinded for findings on daily routine CXRs and were only informed if something deemed important was seen by the radiologist (predefined major abnormalities) who reviewed all CXRs as usual. The second part comprised a half-year period during which daily routine CXRs were replaced by clinically indicated CXR. Mixed medical-surgical ICU of a teaching hospital. Data on 1,780 daily routine CXRs in 559 hospital admissions were collected. DE of daily routine CXRs was 4.4%. The most frequent unexpected major abnormalities were new or progressive infiltrates (1.8%) and oropharyngeal tube malposition (0.7%). TE of daily routine CXRs was 1.9%. The most frequent intervention was oropharyngeal tube adjustment (0.6%). No relation was found for DE or TE and hospital admission type or intubation and mechanical ventilation. In the second study part, 433 CXRs were obtained in 274 admissions. Abandoning daily routine CXRs did not affect clinically indicated CXRs orders, or ICU LOS, readmission rate, and mortality. A total CXR volume reduction of 35% (which equaled 9,900 per bed per year [US dollars]) was observed after abandoning daily routine CXRs. Diagnostic and therapeutic value of the daily routine CXR is low. Daily routine CXRs can be safely abandoned in the ICU.

Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

We sought to determine the effect of elimination of daily routine chest radiographs on chest radiographic practice in cardiothoracic surgery patients in the intensive care unit and the post-intensive care unit ward. We used a prospective, comparative study design with an intervention in a 28-bed intensive care unit/post-intensive care unit ward (including a 4-bed medium-care unit) in a university hospital. Cardiothoracic surgery patients were admitted to the intensive care unit during a period of 6 months (3 months before intervention and 3 months after intervention). Daily routine chest radiographs in the intensive care unit were eliminated; all chest radiographs required a clinical indication. Routine chest radiographs were not performed in the post-intensive care unit ward, both before and after the intervention. Before intervention, in the intensive care unit 353 daily routine chest radiographs and 261 on-demand chest radiographs were obtained in 175 patients; after intervention, 275 on-demand chest radiographs were obtained in 163 patients. Before intervention, in the post-intensive care unit ward 413 on-demand chest radiographs were obtained in 167 patients; after intervention, 445 on-demand chest radiographs were obtained in 161 patients. In the intensive care unit the number of chest radiographs per patient day decreased from 1.8 +/- 0.6 to 1.1 +/- 0.6. In the post-intensive care unit ward the number of chest radiographs per patient per day was 0.4 +/- 0.2, both before and after the intervention. Slightly more unexpected abnormalities were found in the on-demand chest radiographs after the intervention. No negative influence on chest radiography timing, length of stay in the intensive care unit and hospital, and readmission rate was seen. Elimination of daily routine chest radiographs led to a decrease of the total number of chest radiographs obtained per patient per day in the intensive care unit and did not change chest radiography practice in the post-intensive care unit ward.

Chest radiography practice in critically ill patients: a postal survey in the Netherlands

BackgroundTo ascertain current chest radiography practice in intensive care units (ICUs) in the Netherlands.MethodsPostal survey: a questionnaire was sent to all ICUs with > 5 beds suitable for mechanical ventilation; pediatric ICUs were excluded. When an ICU performed daily-routine chest radiographs in any group of patients it was considered to be a "daily-routine chest radiography" ICU.ResultsFrom the number of ICUs responding, 63% practice a daily-routine strategy, in which chest radiographs are obtained on a daily basis without any specific reason. A daily-routine chest radiography strategy is practiced less frequently in university-affiliated ICUs (50%) as compared to other ICUs (68%), as well as in larger ICUs (> 20 beds, 50%) as compared to smaller ICUs (< 20 beds, 65%) (P > 0.05). Remarkably, physicians that practice a daily-routine strategy consider daily-routine radiographs helpful in guiding daily practice in less than 30% of all performed radiographs. Chest radiographs are considered essential for verification of the position of invasive devices (81%) and for diagnosing pneumothorax, pneumonia or acute respiratory distress syndrome (82%, 74% and 69%, respectively). On demand chest radiographs are obtained after introduction of thoracic drains, central venous lines and endotracheal tubes in 98%, 84% and 75% of responding ICUs, respectively. Chest films are also obtained in case of ventilatory deterioration (49% of responding ICUs), and after cardiopulmonary resuscitation (59%), tracheotomy (58%) and mini-tracheotomy (23%).ConclusionThere is notable lack of consensus on chest radiography practice in the Netherlands. This survey suggests that a large number of intensivists may doubt the value of daily-routine chest radiography, but still practice a daily-routine strategy.

Can We Abandon Daily Routine Chest Radiography in Intensive Care Patients?

Two different schools of thought exist on the utility of daily routine chest radiographs in intensive care unit (ICU) patients: some ICU physicians argue that daily routine chest radiographs are indicated in all patients who have cardiopulmonary problems or are receiving artificial ventilation. Others state that chest radiographs should be made on indication only, for example, following a change in clinical status or change of supportive devices. Most studies on this topic have simply reported the existence of several findings on chest radiographs; some investigators tried to determine whether such findings were new and/or unexpected and whether they caused a therapy change. A restrictive strategy has been compared with a daily routine strategy in only 2 clinical trials: 1 study conducted in a pediatric ICU (pediatric ICUs usually have low mortality rates), and the other a rather small (and probably underpowered) study. The debate about discontinuing daily routine chest radiographs in the ICU is still not settled.

The value of daily routine chest radiographs in intensive care patients

It is uncertain whether daily routine chest radiographs (CXRs) truly affect the daily management of critically ill patients. The consensus opinion of the American College of Radiology, however, is that routine CXRs are indicated in all mechanically ventilated patients http://www.acr.org.

The clinical value of daily routine chest radiographs in a mixed medical–surgical intensive care unit is low

IntroductionThe clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients.MethodThis was a prospective observational study conducted in a 28-bed, mixed medical–surgical ICU of a university hospital.ResultsOver a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care.ConclusionIn the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.

Utility of Daily Routine Portable Chest Radiographs in Mechanically Ventilated Patients in the Medical ICU

To determine whether there is any difference in diagnostic, therapeutic, and outcome efficacy between protocols utilizing daily (ie, routine) chest radiographs (CXRs) and those utilizing clinically indicated (ie, nonroutine) CXRs in mechanically ventilated patients. Prospective, randomized, observational study. A 20-bed medical ICU at a university hospital. Adult patients who had been receiving mechanical ventilation for > 48 h. None. Ninety-four patients who had been intubated for at least 48 h were randomized to receive either routine or nonroutine CXRs and were observed until extubation or death. The percentage of CXRs with new findings was significantly larger in the nonroutine CXR group (53.1%; 120 CXRs) compared to that in the routine CXR group (33.4%; 98 CXRs; odds ratio [OR], 1.59; 95% confidence interval [CI], 1.16 to 2.18; p = 0.004). The number of CXRs with new findings that resulted in interventions was significantly larger in the nonroutine CXR group (26.5%; 60 CXRs) compared to that in the routine CXR group (13.3%; 39 CXRs; OR, 2.0; 95% CI, 1.29 to 3.08; p = 0.002). There was no difference in the mean duration of mechanical ventilation (routine CXR arm, 7.93 days; nonroutine CXR arm, 6.76 days; p = 0.2606), length of ICU stay (routine CXR arm, 11.93 days; nonroutine CXR arm, 9.55 days; p = 0.1936), and total length of hospital stay (routine CXR arm, 19.34 days; nonroutine CXR arm, 16.45 days; p = 0.2199) between the two groups. Although patients in the nonroutine arm of the study received fewer CXRs, adverse outcomes (eg, length of mechanical ventilation, length of hospital stay, length of ICU stay, and mortality) did not increase (p = 0.818). Using the number of CXRs per patient as a surrogate, there was a statistically significant cost savings and decreased radiation exposure in the nonroutine CXR group. For mechanically ventilated patients, a strategy calling for daily routine CXRs compared to CXRs obtained based on clinical indications alone was not associated with reduced ICU or hospital length of stay or with reduced mortality.